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Based on record review and interview the hospital failed to ensure that the medical record contained documented evidence of patient notification of their rights. This deficient practice was evidenced by failing to have the patient/patient representative sign the statement of Patient Acknowledgment of Rights for 2 (#2, #3) of 3 (#1-#3) patients reviewed.
Findings:

A review of the hospital policy titled, "Patient Rights and Responsibilities," effective date: 11/13/2023, revealed in part: "III. Policy Statement B. Each patient/representative shall be informed of the Patient Rights and Responsibilities ... IV. Policy Implementation A. Patient Rights C. Admission and Hospitalization 1. During the admit process, patients/representatives shall be provided with a copy of the Patient Rights and Responsibilities."

Review of Patient #2 and Patient #3's medical records failed to reveal documentation that Patient #2 or Patient #3 were informed of their Patient Rights.

In an interview on 12/10/2024 at 8:59 a.m. S1DQ confirmed that there was no documentation in the medical records that Patient #2 or Patient #3 were notified of their Patient Rights.

Based on record review and interview, nursing staff failed to administer PRN medications in accordance with accepted standards of practice. This deficiency is evidenced by failure of the nursing staff to monitor the therapeutic effect of PRN medications in 1 (#2) of 3 (#1-#3) patients reviewed.
Findings:

Review of hospital policy titled, "Assessment and Reassessment (Hospitalized Patients)," effective date: 12/13/2021, revealed in part: "IV. Procedure C. The patient's plan of care, treatment, and services will be based on needs identified by the patient's assessment, reassessment, response to interventions and results of diagnostic testing. G. Patients will be reassessed at the following times: 6. Response to intervention."

Patient #2
Review of Patient #2's medication administration record revealed the following PRN medications were administered:
11/21/2024 at 5:12 p.m. - Chlorpromazine, 25mg Intramuscular every 6 hours, PRN for Severe Agitation.
11/22/2024 at 12:02 a.m. - Melatonin, 6mg oral tablet, one tablet nightly, PRN for Insomnia.
11/22/2024 at 1:37 a.m. - Chlorpromazine, 25mg Intramuscular every 6 hours, PRN for Severe Agitation.
11/22/2024 at 3:09 a.m. - Lorazepam, 1mg IV Injection, every 6 hours, PRN for Anxiety/Agitation.
11/22/2024 at 4:05 p.m. - Haloperidol, 5mg IV Injection, every 6 hours, PRN for Agitation.
11/30/2024 at 9:28 a.m. - Haloperidol, 5mg IV Injection, every 6 hours, PRN for Agitation.

Further review of Patient #2's medical record and medication administration record failed to reveal a re-evaluation of the effectiveness of the medications listed above.

In an interview on 12/09/2024 at 1:47 p.m., S5TUM confirmed the above mentioned findings and verified that there was no documented re-evaluation of effectiveness. S5TUM also confirmed that all PRN medications and interventions should be re-evaluated by the nurse.