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Based on a review of records, hospital policies and procedures, and staff interviews, the governing body failed to ensure that the hospital protected each patient ' s rights; that treatment plans were updated; that nursing care, assessments and documentation were properly supervised, conducted, and completed; that medications were administered as ordered; and that consents were properly obtained and documented.

Findings were:

Patient treatment plans were not reviewed, revised or updated following a significant change in the patient ' s condition.

Cross refer: CFR 482.13(c)(2)

Nursing care for each patient was not properly supervised and evaluated, including not following chain of command or fall incident reporting policies, not completing and/or documenting patient assessments, and not updating nursing care plans for patient treatment following a significant change in a patient ' s condition.

Cross refer: CFR 482.23(b)(3)

Patient teaching was not provided and informed medication consent was not obtained and documented in the medical record for the administration of psychoactive medications.

Cross refer: CFR 482.24(c)(1)

In 9 out of 13 patient records reviewed, 237 medications were administered outside the 30 minute time frame and not in accordance with physician orders and hospital policy.

Cross refer: CFR 482.23(c)

Review of Governing Body Minutes and Quality & Patient Safety Steering Committee Minutes for 2011 revealed no mention of the above findings. In an interview with the regional compliance officer the afternoon of 11/8/2011, she stated a call was received on the corporate compliance staff hotline on July 28, 2011 regarding the geropsych unit identifying clinical issues, the function of the unit, documentation, and patient care; an audit conducted revealed that 72% of geropsych records that had negative issues that should be corrected. In an interview with the regional risk manager on 11/10/2011, she stated the information from the hotline call and the audits were reported to the hospital president but were not reported to the Governing Body or included in the Quality Assessment and Performance Improvement Program.

Review of hospital policy Quality and Patient Safety Plan Document number PLAN-PI states " The leadership at each facility will ...establish and maintain operational linkage between Risk Management, Case Management, Patient Safety and Performance Improvement. "

Based on review of medical records, hospital policies and procedures, and the hospital failed to protect and promote each patient ' s rights related to medication education, informed consent, and treatment planning.

Findings were:

Patient teaching was not provided and informed medication consent was not obtained and documented in the medical record for the administration of psychoactive medications.

Cross refer: CFR 482.24(c)(1)

Nursing care for each patient was not properly supervised and evaluated, including not completing and/or documenting patient assessments related to falls and deteriorating medical condition, and not updating nursing care plans for patient treatment following a significant change in the patient ' s condition.

Cross refer: CFR 482.23(b)(3)

Patient treatment plans were not reviewed, revised or updated following a significant change in the patient ' s condition.

Cross refer: CFR 482.13(c)(2)

Based on review of medical records and staff interviews, the hospital failed to ensure that each patient had an updated treatment plan to provide for care in a safe setting after a fall and significant change in condition.

Findings were:

Review of 2 out of 14 records revealed that the treatment plan was not reviewed, revised or updated following a fall in the hospital and a significant change in the patient ' s condition:

1. Patient #9, an 81 year old female, admitted to the geropsych unit on 6/4/11, experienced a fall and landed on her buttocks on 6/6/11. Physician progress note on 6/7/11 stated " sacral x-ray - possible fx at s3 ...fx - likely fall related. " The patient ' s treatment plan was not revised or updated after the patient ' s fall to reflect the possible fracture.

2. Patient #11, a 70 year old female admitted to the geropsych unit on 6/2/11, experienced a fall and hit the back of her head, with a 1 ? inch laceration to the occipital region of the head on 6/11/11. The patient ' s treatment plan was not revised or updated after the patient ' s fall to reflect the head injury.

Based on review of hospital documentation, patient records, and interview with staff, the hospital failed to ensure that nursing care was properly supervised and evaluated and chain of command was followed in reporting needed medical attention, that patient assessments were completed, accurate, and documented, that care plans were updated following a significant change in a patient ' s conditions, that medication teaching and informed consent were completed, and that medications were administered as ordered and per policy.

Findings were:

Nursing care for each patient was not properly supervised and evaluated, including not following chain of command or fall incident reporting policies, not completing and/or documenting patient assessments, and not updating nursing care plans for patient treatment following a significant change in a patient ' s condition.

Cross refer: CFR 482.23(b)(3)

Patient treatment plans were not reviewed, revised or updated following a significant change in the patient ' s condition.

Cross refer: CFR 482.13(c)(2)

The hospital failed to ensure that patient teaching was provided and informed medication consent was obtained and documented in the medical record for the administration of psychoactive medications.

Cross refer: CFR 482.24(c)(1)

In 9 out of 13 patient records, 237 medications were administered outside the 30 minute time frame in accordance with physician orders and hospital policy.

Cross refer: CFR 482.23(c)

Based on review of records, hospital policies and procedures, and staff interviews, the hospital failed to ensure that a registered nurse properly supervised and evaluated the nursing care for each patient, including not following chain of command or fall incident reporting policies, not completing and/or documenting assessments, and not updating nursing care plans.

Findings were:

Patient #5, a 57 year old female was admitted on 5/16/11 at 2100 from the telemetry/medical unit to the geropsych unit in a catatonic state. Nursing notes document that patient had no oral intake or no urinary output, was rigid, unresponsive, clammy, sweaty skin, jaw clenched, eyes fixated and drooling; the physician was notified four times. The patient remained on the geropsych unit in this state for 17 hours until transferred to the telemetry/medical unit on 5/17/11 at 1400. The nurse continued to document contact with the physician, but did not follow nursing policy regarding chain of command notification of the patient ' s lack of intake or output and deteriorating medical condition and need for medical assessment for 17 hours. The nursing care plan was not updated to reflect this significant change in condition and the patient was not transferred when it was determined that the patient had more serious physical problems than the staff on the geropsych unit could handle.

Patient #9, an 81 year old female sustained a fall on her buttocks in the geropsych unit on 6/6/11. An x-ray of sacral and coccyx region was completed on 6/6/11. Physician progress note on 6/7/11 stated " sacral x-ray - possible fx at s3 ...fx - likely fall related. " There was no nursing documentation in the record to reflect assessment of the patient ' s injury after the initial documentation of the fall. A fall incident report was not completed for the patient ' s fall, and the nursing care plan was not updated to reflect the patient ' s injury. The nursing care plan was not updated to reflect this significant change in condition.

Patient #10 a 66 year old male was admitted to the geropsych unit on 5-10-11 with the diagnosis, " decubitus of heels, status post fracture of ankle. " Order on 5/10/11 at 2030, " waffle boots for decubitus heels on admission. " Nursing patient care records shift documentation revealed the following inconsistencies and inaccurate or incomplete assessments:
5/10/11 7 pm - 7 am Wound/lesion " decubitus both heels "
5/11/11 7am - 7pm Checked " N " [No] for Decubitus ulcer and wrote " none " in the space provided; circled " N/A " for Wound/Lesion, wrote " n/a " for risk for pressure ulcer development.
5/11/11 7pm - 7am Checked " N " [No] for Decubitus ulcer, circled " N/A " for Wound Lesion.
5/12/11 7 am - 7 pm Pressure ulcer assessment left blank/not completed.
5/12/11 7 pm - 7 am Wound/lesion circled " N/A " ; Decubitus Ulcer space left blank.
5/13/11 7 am - 7 pm Pressure ulcer assessment stated " 2 decubs to both heels has waffle boots "
5/13/11 7 am - 7 pm Wound/lesion left blank; decubitus ulcer space left blank.
5/13/11 7 pm - 7 am Wound/lesion left blank; decubitus ulcer space " bilat II heels. "
5/14/11 7 am - 7 pm Pressure ulcer assessment wrote " n/a "
5/14/11 7 am - 7 pm Wound/lesion left blank; decubitus ulcer checked " N " [No] and wrote " none " .
5/14/11 7 pm - 7 am Wound/lesion circled " N/A " ; Decubitus Ulcer space wrote " Stage III bilat heels. "
5/15/11 7 am - 7 pm Pressure ulcer assessment stated " Site A Stage III resolving; Site B Stage III resolving. "
5/15/11 7 am - 7 pm Wound/lesion left blank; decubitus ulcer checked " N " [No] and wrote " none " .
5/15/11 7 pm - 7 am Wound/lesion space wrote " dry flaky " ; decubitus ulcer checked " Y " [Yes] and wrote " bilateral heels III " .

Patient #11, a 70 year old female admitted to the geropsych unit on 6/2/11 fell to the floor on 6/11/11 at 2230, hitting the back of her head on the floor and had a 1 ? inch laceration to the occipital region of the head, which was oozing blood. The nurse notified the physician and the emergency department physician was to evaluate the patient for the head injury. The patient was not medically evaluated until the following morning, 6/12/11 at 0830. During the night, the nurse notified the physician twice and the house officer that the patient had not been evaluated, documenting that, " pt continues to have small amt of oozing, fresh blood, " but the notification chain of command policy was not followed and the patient was not medically evaluated for her laceration and head injury for 12 hours.

Review of 3 of 12 records revealed that fall interventions or assessments were not completed as ordered on the geropsych unit.

1. Patient #4 had a physician ' s order for fall precautions. On 6/17/11 between 7 am and 7 pm, there was no documentation of nursing fall interventions.
2. Patient #10 had a physician ' s order for fall precautions. On 5/13/ between 7 am and 7 pm, there was no documentation of nursing fall interventions.
3. Patient #11, a 70 year old female had a physician ' s order for fall precautions. On 6/11/11, the falls prevention risk assessment (completed every shift and prn) was not completed for the 7 am - 7 pm shift.

Review of hospital policy Physician Notification Protocol/Chain of Command Document number LD-MS-06 stated " A. When a staff member has a concern regarding a medical staff issue, the staff member will speak with the medical staff member regarding the concern. B. If the staff member believes the issue is not resolved or requires more review, the staff member will contact the ...house officer ...depending on the severity of the situation or issue, or inappropriate response from attending physician, the department director/house officer in consultation with the administrator on call, may elect to notify the chief of staff at the facility. "

Review of hospital policy Medical Readmission and/or Transfer to Behavioral Health Units Document number BH-23 states, " Periodically, behavioral health patients develop more serious physical problems than staff on the Unit can handle. When this occurs, it is important to assess what level of care the patient needs and transfer the patient to a medical/surgical floor. "

Review of hospital policy Adult Patient Fall Prevention Document number RM-PS-07 stated " E. Follow-up after a fall ...4.The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient. " The policy also states that " At a minimum, upon admission and twice daily completed the Hendrich II-Patient Fall Risk Assessment ...to determine fall interventions to be initiated. "

In an interview with the hospital risk manager on 11-10-11 at 12:20 pm, she stated there was no falls incident report completed by the nurse for the fall episode for Patient #9.

Based on a review of hospital policies and a review of patient records, in 9 out of 13 patient records on the geropsych unit, 237 medications were administered outside the 30 minute time frame in accordance with physician orders and hospital policy.

Findings were:


Patient #1 received 49 total medications which not given within 30 minutes as ordered or scheduled, including the following:

6-17-11
Buspirone ordered to be given at 2000, given at 2135.
Trazadone ordered to be given at 2200, given at 2135.
Prilosec ordered to be given at 0730, given at 0900.
Carafate ordered to be given at 0800, given at 0900; ordered to be given at1800, given at 1900.

6/20/11
Reglan, ordered to be given at 1400, given at 1320; ordered to be given at 1900, given at 2100.
Buspar ordered to be given at 0800, given at 0850.
Robaxin ordered to be given at 1400, given at 1320; ordered to be given at 1900, given at 2100.
Prilosec ordered to be given at 1630, given at 1750.
Xanax ordered to be given at 1900, given at 2100.
Carafate ordered to be given at 0800, given at 0850.

6/21/11
Reglan, ordered to be given at 0900, given at 0825; ordered to be given at 1900, given at 1800.
Buspar ordered to be given at 2000, given at 2110.
Trazadone ordered to be given at 2200, given at 2110.
Robaxin ordered to be given at 0900, given at 0825; ordered to be given at 1400, given at 1325, ordered to be given at 1900, given at 1800.
Vitamin D ordered to be given at 0000, given at 2306.
Prilosec ordered to be given at 0730, given at 0825.
Xanax ordered to be given at 0900 given at 0825; ordered to be given at 1400, given at 1325; ordered to be given at 1900, given at 1800.
Cymbalta ordered to be given at 2000, given at 2110.
Norvasc ordered to be given at 0900, given at 0825.

6/22/11
Buspar ordered to be given at 2000, given at 2120.
Trazadone ordered to be given at 2200, given at 2120.
Prilosec ordered to be given at 1830, given at 2120.
Carafate ordered to be given at 2300, given at 2200.
Cymbalta ordered to be given at 2000, given at 2120.

6/25/11
Reglan ordered to be given at 1900, given at 2217.
Buspar ordered to be given at 0800, given at 0835; ordered to be given at 2000, given at 2217.
Robaxin, ordered to be given at 1900, given at 2217.
Prilosec ordered to be given at 0730, given at 0835; ordered to be given at 1630, given at 1800.
Carafate ordered to be given at 1300, given at 1355; ordered to be given at 2300, given at 2217.
Cymbalta ordered to be given at 0800, given at 0835; ordered to be given at 2000, given at 2217.
Remeron, ordered to be given at 2100, given at 2217.

6/26/11
Reglan ordered to be given at 1900, given at 2140.
Buspar ordered to be given at 2000, given at 2140.
Robaxin ordered to be given at 1900, given at 2140.
Prilosec ordered to be given at 0730, given at 0830.
Carafate ordered to be given at 2300, given at2200.
Cymbalta ordered to be given at 2000, given at 2140.

Patient #2 received 20 total medications which not given within 30 minutes as ordered to be given at or scheduled, including the following:
9/23/2011
Colace ordered to be given at 0900, given at 0825.
Prilosec ordered to be given at 0900, given at 0645.
Lumigan ordered to be given at 2100, given at 2000.
Flonase ordered to be given at 0900, given at 0825.
Zocor ordered to be given at 2100, given at 2000.
Micardis ordered to be given at 0900, given at 0825.
Seroquel ordered to be given at 0900, given at 0825.

9/24/11
Prilosec ordered to be given at 0900, given at 0615.
Lumigan ordered to be given at 2100, given at2000.

9/25/11
Lumigan ordered to be given at 2100, given at 2020.
Zocor ordered to be given at 2100, given at 2020.
Protonix ordered to be given at 0900, given at 0700.
Zoloft ordered to be given at 0900, given at 1315.

9/27/11 Lumigan ordered to be given at 2100, given at 2005.
Flonase ordered to be given at 0900, given at 0820.
Zocor ordered to be given at 2100, given at 2005.
Micardis ordered to be given at 0900, given at 0820.
Seroquel ordered to be given at 0900, given at 0820.
Protonix ordered to be given at 0900, given at 0630.

9/28/11
Protonix ordered to be given at 0900, given at 0650.

Patient #3 received 7 total medications which not given within 30 minutes as ordered to be given at or scheduled, including the following:
5/10/11
Colace ordered to be given at 2000, given at 2122.
Prilosec ordered to be given at 0730, given at 0650.
Aricept ordered to be given at 0900, given at 1255.
Norvasc ordered to be given at 0900, given at 1255.
Fragmin ordered to be given at 0800, given at 1255.
5/13/11
Colace ordered to be given at 2000, given at 1200.
5/15/11
Prilosec ordered to be given at 0730, given at 0630.

In addition, Patient #4 received 19 medications which were not given within 30 minutes as ordered or scheduled; Patient #8 received 7 medications which were not given within 30 minutes as ordered or scheduled; Patient #9 received 81 medications which were not given within 30 minutes as ordered or scheduled; Patient #10 received 9 medications which were not given within 30 minutes as ordered or scheduled; Patient #11 received 37 medications which were not given within 30 minutes as ordered or scheduled; and Patient #12 received 8 medications which were not given within 30 minutes as ordered or scheduled.

In addition, review of the record for Patient #10 revealed an order on 5/12/11 at 2100 for " Haldol 10 mgm po QHS 1st dose now. " There was no documentation in the medication administration record or progress notes to indicate the patient received the now dose of Haldol ordered at 2100 on 5/12/11.

Review of hospital policy Medication Administration and Monitoring Document number MEDMGT-22 states " 3. Doses are considered " on time " for quality review purposes if administered within 30 minutes before or after the scheduled time. "

Based on review of patient records, hospital policies, and staff interviews, the hospital failed to ensure that patient teaching was provided and informed medication consent was obtained and documented in the medical record for the administration of psychoactive medications.

Findings were:

Review of 4 of 12 medical records revealed that patients received psychotropic medications without correct or completed medication consent documented or patient teaching documented in the medical record.
1. Patient #1 received the following psychotropic medications without medication consents or patient teaching documented in the record: Buspar, Cymbalta Xanax, Trazadone, or Remeron.
2. Patient #2 received the following psychotropic medications without medication consents or patient teaching documented in the record: Seroquel, and Zoloft.
3. Patient #12 received the following psychotropic medications without medication consents or patient teaching documented in the record: Ambien, Thorazine, and Saphris.
4. Patient #9 had no documentation in the medical record to indicate that the patient had a medical power of attorney or guardian. The patient gave verbal consent for the medication Depakote on 6/11/11, but on 6/2/11, her granddaughter signed the medication consents for Risperdal, Ativan, and Ambien. There was no documentation in the record that the patient gave informed consent or received patient teaching for the medications Risperdal, Ativan, and Ambien.

Review of hospital policy Informed Consent for Psychoactive Medications Document number BH-40 states " Prior to initiation of Psychoactive Agents, the person being treated shall be informed of the potential benefits and risks of the prescribed medication, and that information is documented in the medical record ...For each individual medication, a separate form (MHRS 9-7) will need to be completed ...All patient teaching done needs to be documented on the form MHRS 9-7, and in addition needs to be recorded in the progress notes of the medical record. " The above was confirmed in interview with staff #2.

Based on review of records and available documentation, the hospital failed to ensure that evaluations were conducted as ordered and included in the medical record.

Findings were:

Review of 5 of 12 records on the geropsych unit revealed that physical therapy evaluations and treatment were ordered on admission, but physical therapy evaluations and treatment results or findings were not included in the medical record. The records for patient #2, patient #4, patient #8, patient #9, and patient #12 contained orders for a physical therapy evaluation and treatment. There was no evidence in the record indicating that these patients received a physical therapy evaluation or physical therapy treatment.