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Based on policy/procedure review, record review, and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the RN to notify the physician or place an order for a dietary consult for a patient with significant weight loss for 1 (Patient #3) of 5 sample patients.
Findings:

Review of the Hospital's Policy/Procedure PE.052 titled "Assessment of Patients" revealed in part:
Policy - All patients admitted will be weighed on admission, at least weekly thereafter, or more often if indicated and recorded as part of the individualized treatment plan.
Procedure - All patients with a weight loss of 10 pounds or more and/or a weight gain of 10 pounds or more is considered a significant change in weight and must be addressed. The RN must notify the physician of the significant change in weight. Place an order for a Dietary Consult.

Review of Patient #3's Medical Record revealed an admit weight of 146 pounds on 07/29/2019 and a weight of 115 pounds on 08/18/2019. This was a total weight loss of 31 pounds over a period of 23 days. The patient was discharged on 08/21/2019. Further review of the chart failed to reveal the physician was notified or a dietary consult was ordered for the significant weight loss.

During an interview on 10/22/2019 at 2:00 p.m., S1CNO, after reviewing Patient #3's medical record, acknowledged the patient's significant weight loss had not been addressed.

Based on policy/procedure review, record review, and interview, the hospital failed to ensure the nursing staff developed and kept current, individualized and comprehensive nursing care plans. This deficient practice was evidenced by failure of the nursing staff to update the nursing care plan for a patient with significant weight loss for 1 (Patient #3) of 5 sample patients.
Findings:

Review of the Hospital's Policy/Procedure PE.052 titled "Assessment of Patients" revealed in part:
Policy - All patients admitted will be weighed on admission, at least weekly thereafter, or more often if indicated and recorded as part of the individualized treatment plan.
Procedure - All patients with a weight loss of 10 pounds or more and/or a weight gain of 10 pounds or more is considered a significant change in weight and must be addressed.

Review of Patient #3's Medical Record revealed an admit weight of 146 pounds on 07/29/2019 and a weight of 115 pounds on 08/18/2019. The patient was discharged on 08/21/2019. This was a total weight loss of 31 pounds over a period of 23 days. Further review of the chart failed to reveal the patient's care plan was update to address the significant weight loss.

During an interview on 10/22/2019 at 2:00 p.m., S1CNO, after reviewing Patient #3's medical record, confirmed the patient's care plan was not updated to address the patient's significant weight loss.

Based on policy/procedure review, record review, and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with orders of the practitioners responsible for the patient's care. This deficient practice is evidenced by failure of the nursing staff to administer an antipsychotic medication according to the physician's orders.
Findings:

Review of Hospital's policy MM.055 titled, "Medication Administration Authorization" revealed in part: Medications not eligible for scheduled dosing times are medications that require exact or precise timing of administration, based on diagnosis type, treatment requirements, or therapeutic goals. Timing of Medication Administration - The following medications orders are not eligible for standardized scheduled dosing times. Medications prescribed on an as needed or PRN basis.
Policy - Medications and biologicals are administered upon the order of a practitioner responsible for the care of the patient.
Medication Administration Procedure - Verifies the medication is administered at the appropriate time, to ensure adherence to the prescribed frequency and time of administration.

Review of Patient #3's Physician's Orders revealed in part: Haldol 5mg injection as needed every 8 hours for agitation.

Review of Patient #3's Medication Administration Record revealed Haldol 5mg injections were administered on 08/01/2019 at 11:46 a.m. and again at 5:15 p.m. Time between injection was 5 hours and 29 minutes. The physician's order was for every 8 hours.

During an interview on 10/22/2019 at 4:58 p.m., S1CNO, after reviewing the medical record, acknowledged the Haldol was not administered as ordered by the physician.

During an interview on 10/22/2019 at 3:14 p.m., S2LPN stated she remembered giving patient #3 medication during periods of aggressive behavior. She continued to state she was unaware that she had given the medication earlier than it was ordered. Review of the patient's medical record at this time failed to reveal the doctor was notified or a that one-time dose was ordered.