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Based on policy and procedure review, staffing assignment sheet review, and interview, it was determined the facility failed to ensure the mandatory elements were documented on the Staff Assignment sheets as required by policy and procedure for two (Autumn and Winter) of three (Autumn, Spring and Winter) patient units for 22 of 29 days on the Autumn Unit and 20 of 29 days on the Winter Unit. Failure to document the required elements on the Staff Assignment sheets did not ensure staff were aware of who was responsible for what patient, times staff could potentially be off the unit for meals or breaks, and did not ensure staff were aware of unit assignments such as unit clean up, vital signs, and every 15 minute check sheets and meals. The failed practice had the potential to affect all patients on the two units from 02/023/19 through 03/03/19. Findings follow:

A. Review of the policy and procedure titled "Assignment of Nursing Staff," received from the Chief Nursing Officer (CNO) at 11:22 AM on 03/04/19 showed the following was to be documented on the Staffing Assignment Sheet at the beginning of each shift:
1) Staffing assignments
2) The name and title of the staff member to be assigned.
3) The names of the patients assigned to the staff member.
4) Break, mealtime and non-direct care assignments.

B. Review of the Staff Assignment sheets for the Winter unit showed the following days did not have the above information (A.1-4) documented on the sheets: 02/03/19 - 02/12/19, 02/14/19, 02/17/19, 02/19/19, 02/20/19, 02/23/19, 02/24/19, 02/27/19-03/01/19 and 03/03/19.

C. Review of the Staff Assignment sheets for the Autumn unit showed the following days did not have the above information (A.1-4) documented on the sheets: 02/03/19, 02/05/19 - 02/08/19, 02/10/19-02/14/19, 02/18/19 - 02/21/19, 02/24/19 - 03/03/19.

D. The findings in A, B and C were verified during an interview with the CNO at 11:30 AM on 03/04/19 and again during an interview at 2:00 PM on 03/06/19.

Based on clinical record review and interview, it was determined a Registered Nurse failed to assess and manage the care of five (#1, #2, #12, #14 and #15) of sixteen (#1-16) patients in that treatment/medications were not administered as ordered by the physician. Failure to provide the treatment and assess the effects had the potential to prolong the patient's hospitalization and recovery time. The failed practice had the potential to affect Patients #1, #2, #12, #14, and #15. Findings follow:

A. Review of Patient #1's clinical record showed orders authored by Physician #2 on 09/03/18 which included the following: CIWA (Clinical Institute Withdrawal Assessement) every two hours while awake for 72 hours, then TID (three times a day) and then PRN (as needed). The original order was discontinued on 09/06/18 and restarted on 09/07/18 at TID only. The CIWA scores dictated the amount of Ativan the patient was to receive: Ativan 0.5 mg (milligram) for a CIWA score of 7-15, 1 mg for a CIWA score of 16-30 and 2 mg for a CIWA score greater than 30 for 6 days duration. Review of the CIWA assessment sheets and Medication Administration Record (MAR) for Patient #1 showed the following:
1) 09/04/18
a. 8:00 AM - CIWA Score 19 - no Ativan documented as given.
b. 12:00 PM - CIWA Score 20 - no Ativan documented as given
c. 2:00 PM - CIWA Score not documented 1 mg (milligram) of Ativan documented as given
d. 4:00 PM - CIWA Score 19 - no Ativan documented as given
e. 5:30 PM - Ativan 1 mg documented as given
f. 6:00 PM - CIWA Score 4
g. 8:00 PM - CIWA Score 21 - no Ativan documented as given.
h. 9:00 PM - Ativan 2 mg documented as given - score indicated 1 mg should have been given.
2) 09/05/18
a. 6:00 PM - CIWA Score 18 - 2 mg documented as given - score indicated 1 mg should have been given.
b. 8:00 PM - CIWA Score 18 - 2 mg documented as given - score indicated 1 mg should have been given.
3) 09/08/18
a. 8:00 AM - CIWA Score 17 - no Ativan documented as given.
4) 09/09/18
a. No time documented for first CIWA Score.
5) 09/10/18
a. 8:00 AM - CIWA Score 33 charted - but adding the ten indicators gave a score of 23.
b. 2:00 PM - CIWA Score 32 charted - but adding the ten indicators gave a score of 20.
6) 09/11/18
a. 8:00 PM - CIWA Score 20 - no Ativan documented as given.

Review of the nurse's note dated 09/07/18 showed the patient was questioning his medications. Review of two nurse's notes each dated 09/09/18 showed Patient #1 did not always take his medications (there are no entries in the clinical record which showed refusals) and that patient was asking to be scored because he felt anxious. During an interview with the Chief Nursing Officer (CNO) at 2:15 PM on 03/05/19 all of the above findings were verified.

B. Review of Patient #2's clinical record showed physician's orders for Trazodone 100 mg by mouth every night. Review of the clinical record showed no documentation Patient #2 received the Trazodone on 09/09/18. During an interview with the CNO at 9:04 AM on 03/06/19 the above findings were verified.

C. Review of Patient #12's clinical record showed physician's orders for Clonidine .05 mg by mouth TID. Review of the clinical record showed no documentation Patient #12 received the Clonidine at the 8:00 PM dose on 03/03/19 and the 2:00 PM dose on 03/04/19. During an interview with the CNO at 12:38 PM on 03/05/19 the above findings were verified.

D. Review of Patient #14's clinical record showed physician's orders for Divalproex 500 mg by mouth every morning. Review of the clinical record showed no documentation Patient #14 received the Divalproex on 03/03/19. During an interview with the CNO at 1:31 PM on 03/06/19 the above findings were verified.

E. Review of Patient #15's clinical record showed physician's orders for Propanol 20 mg by mouth TID. Review of the clinical record showed no documentation Patient #15 received the Propanol at 8:00 PM on 02/28/19, at 2:00 PM on 03/01/19 and 03/02/19. During an interview with the CNO at 1:28 PM on 03/06/19 the above findings were verified.


Based on clinical record review and interview, it was determined a Registered Nurse failed to assess and manage the care for three (#2, #3 and #12) of four (#1, #2, #3, and #12) patients whose physician ordered vital signs to be checked twice a day. Failure to ensure the vital signs were checked twice a day did not allow the physician access to information needed to make informed decisions regarding the care and treatment of the patients. The failed practice affected Patient #2, #3, and #12. Findings follow:

A. Review of Patient #2's clinical record showed orders authored by Physician #2 on 09/09/18 for vital signs to be checked BID (twice a day). Review of Patient #2's clinical record showed no evidence vital signs were performed and documented BID for eight (09/09/18 through 09/16/18) of eight days. The CNO verified the findings during an interview at 9:04 AM on 03/06/19.

B. Review of Patient #3's clinical record showed orders authored by Physician #2 on 09/15/18 for vital signs to be checked BID. Review of Patient #3's clinical record showed no evidence vital signs were performed and documented BID for 17 of 17 (09/15/18 through 10/01/18) days. The CNO verified the findings during an interview at 9:15 AM on 03/06/19.

C. Review of Patient #12's clinical record showed orders authored by Physician #3 on 02/24/19 for vital signs to be checked BID. Review of Patient #12's clinical record showed no evidence vital signs were performed and documented BID for five (02/25/19 through 02/28/19 and 03/04/19) of eight (02/05/19 through 03/04/19) days. The CNO verified the findings during an interview at 12:38 PM on 03/05/19.



Based on clinical record review and interview, it was determined the Registered Nurse failed to assess and manage the care of two of two (Patient #1 and Patient #4) patients admitted to the detox (detoxification) program in that the every two hour assessments ordered by the physician were not performed and the results documented. Failure to assess the patient every two hours as ordered did not give the physician and other staff the physical information needed to make care and treatment decisions based on the assessment results. The failed practice affected Patient #1 and Patient #4. Findings follow:

A. Review of the CIWA (Clinical Institute Withdrawal Assessment) protocol, received from the Director of Risk and Performance Improvement on 03/05/19, showed the patient admitted to the detox program was to be assessed and scored every two hours while awake for 72 hours then TID (three times a day) and PRN (as needed) for 72 hours.

B. Review of Patient #1's clinical record showed an admission date and time of 09/03/18 at 9:15 PM. Review of the clinical record showed Patient #1 was not assessed and scored at 2:00 PM on 09/04/18. The CIWA was discontinued at 3:00 PM on 09/06/18 and re-started on 09/07/18 at 5:00 PM. Review of the clinical record showed Patient #1 was assessed and scored TID on 09/09/18 but the time of the first assessment and scoring is not documented. During an interview with the CNO at 1:38 PM on 03/06/19 the above findings were verified.

C. Review of Patient #4's clinical record showed an admission date of 09/28/18. Review of the clinical record showed Patient #4 was not assessed and scored every two hours from 9:00 AM to 11:45 AM on 09/29/18, and from 2:28 PMto 8:00 PM on 09/29/18. During an interview with the House Supervisor at 9:21 AM on 09/06/18 the above findings were verified.

Based on review of Arkansas Rules and Regulations for Hospitals and Related Institutions, the Emergency Cart Checklists, and interview, it was determined the facility failed to check the emergency crash cart every shift. Failure to check the crash cart every shift did not assure equipment and supplies were available and functional in the event of an emergency. The failed practice had the potential to affect all patients in the facility. Findings follow:

A. Review of the Arkansas Rules and Regulations for Hospitals and Related Institutions, Section 12.S.4.e, showed emergency carts were to be checked for the integrity of the seal each shift and each check documented.

B. Review of the "Equipment Unit Checklist," received from the Director of Risk and Performance Improvement at 11:30 AM on 03/05/19, showed the Unit Checklist was to be completed once in a 24 hour period by the day or night staff.

C. Review of the Equipment Unit Checklists for the Spring/Summer Unit and the Autumn/Winter Unit showed the emergency carts were only checked once a day.

D. During an interview with the Chief Nursing Officer at 3:00 PM on 03/05/19 the findings in B and C were verified.

Based on observation and interview, it was determined the facility failed to date when opened, and discard, multi dose vials of medication in two of two (Summer and Winter/Autumn) Units. Failure to date when opened multi dose vials of medication and failure to discard undated multi dose vials of medications did not ensure the patients were not receiving medications that should have been discarded. The failed practice had the potential to affect any patient whose care required Lantus insulin and Tubersol for Tuberculin screening. Findings follow:

A. Observation on the Winter/Autumn Unit showed one vial of Lantus 100 Units/milliliter vial opened and undated as to when it was opened. The above findings were verified during an interview with LPN (Licensed Practical Nurse) #1 at 2:30 PM on 03/04/19.

B. During an interview with LPN #1 at 2:32 PM on 03/04/19 she was asked if the Lantus should have been dated when opened and she stated yes. LPN #1 was asked how long the vial should have been dated for and she stated "30 days."

C. Observation on the Summer Unit showed two vials of Tubersol in the medication refrigerator; one was dated 11/28/18 as the opened date and the other was open and not dated. During an interview with the Chief Nursing Officer at 2:53 PM on 03/04/19 the findings in A and C were verified.