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Based on observation, interview and record review it was determined the facility did not have an effective Governing Body based on the deficiencies cited at A049, A130 and A145. Failure to have an effective Governing Body put all patients within the facility at risk for harm.

Based on clinical record review, it was determined the Governing Body failed to ensure safe medical services were provided for 2 (#1 and #2) discharged patients of the 8 (#1-#8) patient records reviewed for patients requiring services of the Behavioral Health Unit. The neglect by facility staff resulted in symptomatic dehydration requiring additional medical interventions and potentially affected the attainment of goals and overall care and safety of the 11 patients currently admitted to the Behavioral Health Unit. Findings are as follow:

A. Review of Clinical Record #1 with an admission date of 02/21/12 revealed a history of dementia and a 17 day hospitalization on the Behavioral Health Unit. Documentation on the form titled "Psychiatric Nursing Admission Assessment" dated 02/21/12 revealed the patient had a "Recent decline in functioning of ADLs" specific to bathing, dressing and eating. The patient's documented weight at the time of admission was 113 pounds.

1) A document in the clinical record titled, "Interdisciplinary Treatment Plan", dated 02/21/12 failed to include interventions specific to a physician or a signature of approval by a physician. The document was subsequently signed by the Psychiatrist's electronic signature on 03/14/22 (22 days after the patient was admitted to the Behavioral Health Unit).

2) The patient's nutritional status was identified by the Dietitian and documented on an "Adult Nutrition Initial Assessment" conducted on 02/28/12 which revealed the patient's "meal intake averaged 74%...pt ambulates per self ...weight was stable. Fluid intake avg [average] 1018 ml/3 D [3 days]". Based on the assessment, the "Nutrition Plan of Care" stated, "Dietitian follow up/monitor, Encourage PO Feedings. Dietitian Follow-up in 5 days and Oral Intake Goal: 100%." Beginning the evening of 03-03-12 documentation by the nursing staff revealed the patient had no food intake and a significant decline in overall fluid intake.

3) Dictation by the Psychiatrist on a "Progress Note" dated 03/05/12 stated, "Unfortunately, increased lethargy is occurring with a fever. Other vital signs are stable ...Sleep and appetite are poor ...going to hold Seroquel ...and contact [attending physician] to see what he might workup on this fever." There was no evidence in the clinical record the attending physician was contacted by either the Psychiatrist or the clinical staff.

4) The Psychiatrist's dictated "Progress Note" of 03/06/12 stated, "Good news...No outburst but still a little bit lethargic ...Sleep and appetite are good ...". The nursing staff documented on the "Patient Graphic" for this same date of 03/06/12 no intake of food for any of the 3 meals and a total intake of 150cc for the entire day.

5) The Psychiatrist's dictated "Progress Note" for 03/07/12 stated, "Unfortunately, there is a continuation of lethargy. I am not calling it sedation at this point ...It is more physical in nature. She is not drinking well or eating hardly at all ...going to get [attending physician] involved ...".

6) An RN "Progress Note" of 03/07/12 at 1730 stated, "Bolus of NS 550 ml started on pt due to order from [medical doctor] ..." and on 03/08/12 at 1445, the RN documented the patient was transferred to a medical floor after a CT scan identified an intracranial bleed.

7) A reassessment conducted by the Dietitian on the morning of 03/08/12 (9 days after the initial assessment) reflected the patient's "meal intake average was 25%, the patient was not meeting nutrition needs for kcal [kilo calories] or protein and a weight of 106 lbs on 03/05/12 was a decrease of approximately 6 lbs from admit weight".

8) There was no evidence of the attending physician or any medical physician's presence with the patient during the patient's 17 day hospitalization on the Behavioral Health Unit. The attending physician dictated a "History and Physical" for the patient on 02/24/12 (3 days after admission), but no original physician documentation of progress notes, orders or signatures were identified in the clinical record. Verbal orders were received from the attending physician on 03/07/12 at the request of the Psychiatrist for IV fluids and assistance to determine the cause of the patient's ongoing lethargy.

9) A review of the "Progress Notes" and "Physician Orders" by the Psychiatrist revealed original documentation and signatures on weekend dates of 02/25, 02/26, 03/03 and 03/04/12. No other original notes, orders or signatures were identified for the Psychiatrist and all other "Physician Orders" from the Psychiatrist were received and documented as telephone orders by the staff.

10) Review of physician's orders and progress notes during the patient's 17 day hospitalization identified 15 orders, 13 or (87%) were verbal orders (8 psych, 5 medical) and 2 written orders (2 psych, 0 medical). Of the 10 progress notes (10 psych and 0 medical), 6 were dictated and 4 were original written and signed notes.

B. Review of Clinical Record #2 with an admission date of 11/11/11 revealed a history of dementia and mental status changes and a 12 day hospitalization on the Behavioral Health Unit. Documentation on the "Psychiatric Nursing Admission Assessment" revealed the patient was "not alert to self", disoriented, unable to "monitor nutritional status" and unable to "dress appropriately and groom oneself". In addition, the assessment revealed a new onset of unsteady gait, new onset of incontinence, a decline in bathing, dressing, eating and the patient was unable to provide information as she was nonverbal upon admission.

1) Review of the "Psychiatric Nursing Admission Assessment" revealed there was no evidence a referral for a Physical Therapy (PT), OT or Speech Therapy screen due to the recent decline as directed by the "Functional/Rehabilitation Screen" Section of the Admission Assessment Tool.

2) The "Interdisciplinary Treatment Plan" dated 11/11/11 identified specific to maintaining good personal hygiene included a plan to "Encourage regular showers every other day", "Remind patient to perform daily oral care" and "Assist patient with ADLs". The treatment plan failed to address the patient's needs regarding the new onset of unsteady gait, nutritional needs based on the decline in eating or communication needs based on the patient's nonverbal status.

3) The "History and Physical" for the Patient #2 was dictated by an Advanced Practice Nurse (APN) on 11/12/11 and "e signed" by a physician not assigned to the patient's care on 11/14/11.

4) The patient's nutritional status was evaluated by the Dietitian on 11/17/11 and documentation on the "Adult Nutrition Initial Assessment" revealed the patient's "meal intake averaged 19% and kcal/pro/fluid needs remain unmet. Pt unable to make nutrition needs known ..." Based on the assessment, the "Nutrition Plan of Care" stated, "Dietitian follow up/monitor, Encourage PO Feedings. Dietitian Follow-up in 3 days, Oral Intake Goal: 50 - 75%" and a recommendation for a lab test: Albumin/Pre-albumin. There was no evidence in the clinical record the recommended lab tests were ordered, obtained or reviewed for results.

5) A "Progress Note" on 11/18/11 at 2010 revealed the patient's B/P was 86/43 and a doctor was notified. A verbal order which stated "500 NS (normal saline) Bolus Now. Call [doctor] if B/P (blood pressure) not increased" was identified in the clinical record. A B/P reading at 2200 was 95/66 and a verbal order from an APN dated 11/19/11 stated, "DC (discontinue) HCTZ and Valsartan".

6) A reassessment conducted by the Dietitian on 11/21/11 revealed the "meal intake average was 64%, the patient's nutrition needs may be unmet" and stated "Pt [patient] appeared to do better when fed by family. Is beginning to hold cup and drink fluids better". The nutritional treatment plan reflected a goal for the to eat greater than 75% of meals. No other risks, goals or interventions were identified regarding nutritional status.

7) There was no evidence of the attending physician or any medical physician's presence with the patient during the patient's hospitalization on the Behavioral Health Unit. The verbal order on 11/18/11 for IV fluids due the patient's low blood pressure was an order by a medical physician not previously assigned to the patient's care. In addition, the order by an APN dated 11/19/11 was the only original written medical order in the clinical record and was "e signed" on 12/10/11 (21 days later) by the same physician not assigned to the patient's care.

8) A review of the "Progress Notes" and "Physician Orders" by the Psychiatrist revealed original documentation and signatures on weekend dates of 02/25, 02/26, 03/03 and 03/04/12. No other original notes, orders or signatures were identified for the Psychiatrist and all other "Physician Orders" from the Psychiatrist were received and documented as telephone orders by the staff.
9) Review of physician's orders and progress notes during the patient's 12 day hospitalization identified 12 orders, 11 or (91%) were verbal orders (8 psych, 3 medical) and 1 written order (o psych, 1 medical). Of the 7 progress notes (7 psych and 0 medical), 5 were dictated and 2 were original written and signed notes.
C. The facility's policy #06.004 titled, "Verbal Telephone Orders" states at item #2.0 "The use of verbal orders is discouraged ..." and at item #3.E.a. "All verbal and telephone orders must be authenticated and countersigned ...within 48 hours ...".

Based on observation, interview and record review it was determined the facility did not protect the patients right to be free of abuse and neglect determined by deficiencies cited at A130 and A145. Failure to protect the patients right to be free of abuse and neglect put all patients in the facility at risk for abuse and neglect.

Based on clinical record review it was determined the facility failed to ensure the patient or a patient's representative was given the opportunity to participate in the planning of care in 2 (#1 and #2) discharged records reviewed for patients requiring the services of the Behavioral Health Unit. The failed practice did not allow the patient's individual needs or desires to be incorporated into the treatment plan for care and had the potential to affect the goals and outcomes of 11 patients currently admitted to the Behavioral Health Unit. Findings are as follow:

A. Review of the "Interdisciplinary Treatment Plan" for Clinical Record #1 dated 02/22/12 revealed on the "Patient" signature line a notation which stated, "Pt [patient] confused-cannot sign". On the "Family/SO/POA" line the notation was "No family present".

B. Review of the "Interdisciplinary Treatment Plan" for Clinical Record #2 dated 11/14/11 revealed on the "Patient" signature line a notation which stated, "pt [patient] unable". On the "Family/SO/POA" line the notation was "husband currently in FL [Florida]".

Based on interviews, observations, facility document review and clinical record review, it was determined the facility neglected to meet personal care and nutritional needs of 6 (#1-#4 and #7-#8) of 8(#1-#8) records reviewed for patients requiring services of the Behavioral Health Unit. The neglect by facility staff resulted in symptomatic dehydration requiring additional medical interventions for 2 (#1 and #2) and potentially effects the attainment of goals and overall care and safety of the 11 patients currently admitted to the Behavioral Health Unit. Findings are as follow:

A. During a tour of the Behavioral Health Unit on 05/09/12 at 0830, a copy of the daily activity schedule was requested to determine if times were routinely designated for meals and personal care. The "Daily Program Schedule" was provided for review and presented on a weekly calendar format with hourly events documented for each day. Scheduled times for meals was identified each day for 7:30 Breakfast, 12:00 Lunch and 5:00 Dinner. Personal Hygiene was scheduled twice a day for 7:00 am and 8:00 pm.

B. While on the Unit, an interview was conducted at 1035 with the Charge Registered Nurse (RN) and a Nursing Assistant regarding general patient care routines and documentation. When questioned regarding a form contained within a current patient's record titled, "Patient Care Plan Implementation Phase" both staff stated the form was utilized to document patient care and meals.

C. Review of Clinical Record #1 with an admission date of 02/21/12 revealed a history of dementia and a 17 day hospitalization on the Behavioral Health Unit. Documentation on a form titled "Psychiatric Nursing Admission Assessment" dated 02/21/12 revealed the patient had a "Recent decline in functioning of ADLs" specific to bathing, dressing and eating. The patient's documented weight at the time of admission was 113 pounds.

1) Upon further review of the "Psychiatric Nursing Admission Assessment" there was no evidence a referral was placed for screening by Occupational Therapy (OT) due to the recent decline in ADLs abilities as directed by the "Functional/Rehabilitation Screen" Section of the admission assessment tool.

2) The "Interdisciplinary Treatment Plan" dated 02/21/12 identified interventions specific to maintaining good personal hygiene which included a plan to "Encourage regular showers every other day" "Remind patient to perform daily oral care" and "Assist patient with ADLs".

3) Documentation on the "Patient Care Plan Implementation Phase" record revealed personal hygiene interventions were not conducted as specified by the treatment plan or as scheduled by the "Daily Program Schedule". During the 17 day hospitalization, oral care was documented 2 times (02/23/12 and 03/04/12) instead of daily. A bath or shower was documented 4 times (02/21/12, 02/23/12, 02/29/12 and 03/03 12) instead of every other day as the treatment plan specified.

4) The patient's nutritional status was evaluated by the Dietitian and documented on an "Adult Nutrition Initial Assessment" conducted on 02/28/12 which revealed the patient's "meal intake averaged 74%...pt ambulates per self ...weight was stable. Fluid intake avg [average] 1018 ml/3 D [3 days]". Based on the assessment, the "Nutrition Plan of Care" stated "Dietitian follow up/monitor, Encourage PO Feedings. Dietitian Follow-up in 5 days and Oral Intake Goal: 100%". Beginning the evening of 03-03-12 documentation by the nursing staff revealed the patient had no food intake and a significant decline in overall fluid intake. There was no evidence in the clinical record the nursing staff attempted to intervene in the nutritional decline of the patient until 03/07/12 at 1700 when the nursing staff received a telephone order from the attending physician to start IV (intravenous) fluids.

5) Dictation by the Psychiatrist on a "Progress Note" dated 03/05/12 stated, "Unfortunately, increased lethargy is occurring with a fever. Other vital signs are stable ...Sleep and appetite are poor ...going to hold Seroquel ...and contact [attending physician] to see what he might workup on this fever." There was no evidence in the clinical record the attending physician was contacted by either the Psychiatrist or the clinical staff.

6) The Psychiatrist's dictated "Progress Note" of 03/06/12 stated, "Good news...No outburst but still a little bit lethargic ...Sleep and appetite are good ..." The nursing staff documented on the "Patient Graphic" for this same date of 03/06/12 no intake of food for any of the 3 meals and a total intake of 150cc for the entire day.

7) Documentation by the RN on the "Daily Nursing Assessment" of 03/06/12 stated, "Pt. sedated this morning and would not awake for breakfast. Staff tried to encourage pt to wake up ...pt remained sleepy with no verbalization. Pt's AM meds held due to sedation". There was no evidence in the clinical record a physician was notified of the patient's status.

8) The Psychiatrist's dictated "Progress Note" for 03/07/12 stated, "Unfortunately, there is a continuation of lethargy. I am not calling it sedation at this point ...It is more physical in nature. She is not drinking well or eating hardly at all ...going to get [attending physician] involved ..."

9) A RN "Progress Note" of 03/07/12 at 1730 stated, "Bolus of NS 550 ml started on pt due to order from [medical doctor] ..." and on 03/08/12 at 1445, the RN documented the patient was transferred to a medical floor after a CT scan identified an intracranial bleed.

10) A reassessment conducted by the Dietitian on the morning of 03/08/12 (9 days after the initial assessment) revealed the patient's "meal intake average was 25%, the patient was not meeting nutrition needs for kcal [kilo calories] or protein and a weight of 106 lbs on 03/05/12 was a decrease of approximately 6 lbs from admit weight".

11) There was no evidence of the attending physician or any medical physician's presence with the patient during the patient's 17 day hospitalization on the Behavioral Health Unit. The attending physician dictated a "History and Physical" for the patient on 02/24/12 (3 days after admission). No original physician documentation of progress notes, orders or signatures were identified in the clinical record. Verbal orders were received from the attending physician on 03/07/12 at the request of the Psychiatrist for IV fluids and assistance to determine the cause of the patient's ongoing lethargy.

D. Review of Clinical Record #2 with an admission date of 11/11/11 revealed a history of dementia and mental status changes and a 12 day hospitalization on the Behavioral Health Unit. Documentation by a RN on the "Psychiatric Nursing Admission Assessment" revealed the patient was "not alert to self", disoriented, unable to "monitor nutritional status" and unable to "dress appropriately and groom oneself". In addition, the assessment revealed a new onset of unsteady gait, new onset of incontinence, a decline in bathing, dressing, eating and the patient was unable to provide information as she was nonverbal upon admission.

1) Upon further review of the "Psychiatric Nursing Admission Assessment" there was no evidence a referral for a Physical Therapy (PT), OT or Speech Therapy screen due to the recent decline as directed by the "Functional/Rehabilitation Screen" Section of the admission assessment tool.

2) The "Interdisciplinary Treatment Plan" dated 11/11/11 identified specific to maintaining good personal hygiene included a plan to "Encourage regular showers every other day", "Remind patient to perform daily oral care" and "Assist patient with ADLs". The treatment plan failed to address the patient's needs regarding the new onset of unsteady gait, nutritional needs based on the decline in eating or communication needs based on the patient's nonverbal status.

3) The "History and Physical" for the Patient #2 was dictated by an Advanced Practice Nurse (APN) on 11/12/11 and "e signed" by the attending physician on 11/14/11.

4) The patient's nutritional status was evaluated by the Dietitian on 11/17/11 and documentation on the "Adult Nutrition Initial Assessment" revealed the patient's "meal intake averaged 19% and kcal/pro/fluid needs remain unmet. Pt unable to make nutrition needs known ..." Based on the assessment, the "Nutrition Plan of Care" stated, "Dietitian follow up/monitor, Encourage PO Feedings. Dietitian Follow-up in 3 days, Oral Intake Goal: 50 - 75%" and a recommendation for a lab test: Albumin/Pre-albumin. There was no evidence in the clinical record the recommended lab tests were ordered, obtained or reviewed for results.

5) Documentation by the nursing staff on the daily "Patient Care Plan Implementation Phase" record revealed the intake goal was not met as the patient had poor nutritional intake of less than 50% most meals. After the Dietitian's evaluation, the patient's meal intake averaged 43% for the 16 meals documented from 11/18/11 to 11/22/11.

6) Additional documentation by the nursing staff on the "Patient Care Plan Implementation Phase" also revealed personal hygiene interventions were not provided as specified by the treatment plan or as scheduled by the "Daily Program Schedule". Record of personal care during the 12 day hospitalization revealed oral care was documented 2 times (11/12/11 and 11/15/11) instead of daily and a bath or shower was documented 2 times (11/12/11 and 11/15/11) instead of every other day as the treatment plan specified.

7) A RN "Progress Note" on 11/18/11 at 2010 revealed the patient's B/P was 86/43 and a doctor was notified. A verbal order which stated "500 NS (normal saline) Bolus Now. Call [doctor] if B/P (blood pressure) not increased" was identified in the clinical record. A B/P reading at 2200 was 95/66 and a verbal order from an APN dated 11/19/11 stated, "DC (discontinue) HCTZ and Valsartan".

8) A reassessment conducted by the Dietitian on 11/21/11 revealed "the meal intake average was 64%, the patient's nutrition needs may be unmet" and stated, "Pt [patient] appeared to do better when fed by family. Is beginning to hold cup and drink fluids better". The nutritional treatment plan reflected a goal for the patient to eat greater than 75% of meals. No other risks, goals or interventions were identified regarding nutritional status.

9) There was no evidence of the attending physician or any medical physician's presence with the patient during the patient's hospitalization on the Behavioral Health Unit. The verbal order on 11/18/11 for IV fluids due the patient's low blood pressure was an order by a medical physician not assigned to the patient's care. In addition, the order by an APN dated 11/19/11 was the only original order in the clinical record and was "e signed" on 12/10/11 (21 days later) by the same physician not assigned to the patient's care.

E. While on the Unit, a review of clinical records for 6 of the current 11 patients was conducted. Documentation on the "Patient Care Plan Implementation Phase" record reflected personal hygiene needs were not provided according to the Daily Program Schedule or Interdisciplinary Treatment Plan for 4 (#3,#4,#7 and #8) of the 6 (#3-#8) of the current records reviewed.

1) Clinical Record #3 received 1 shower during an 8 day current hospital stay.
2) Clinical Record #4 received 1 shower during a 6 day current hospital stay.
3) Clinical Record #7 did not receive a bath or shower during a 5 day current hospital stay.
4) Clinical Record #8 received oral care 17 days and received a shower 7 times during a 28 day current hospital stay.

F. During the interview conducted on the Unit at 1035 with the Charge RN and Nursing Assistant, the above findings for the current patients were verified. The Charge RN confirmed if the care was provided it would be documented on the "Patient Care Plan Implementation Phase" record.

G. Review of the facility's job descriptions for the Nursing Assistant identified "Primary Responsibilities" for Patient Care at item #1.1 Assist assigned patient or give baths, oral care and hair care daily as needed, #1.9 Prepare patients for meals, feed patients requiring help, provide between meal and HS nourishment ...and #1.12 Provide HS care to assigned patients; to include back rubs, toilet needs, straighten linen and oral care.

H. The facility's job descriptions for the RN identified "Primary Responsibilities" for Clinical/Technical Performance at item #1.1 Responsible for daily physical care of patients, bath, linen changes, vital signs, I&O, meals.

I. The facility's policy for "Oral Care" with a revision date of March 31, 2012, stated, "Oral care ...is commonly performed in the morning, at bedtime and after meals".

J. The facility's policy #06.003 titled, "Patient and Family Education" stated at item 3.B Good standards of personal hygiene and grooming are taught and maintained to include bathing, brushing teeth, caring for hair and nails and using the toilet with due regard for privacy in accordance with patient's needs.

K. The Facility Representative (Director, Ortho Nursing Services) was present during the interview at 1035 with the Charge RN and Nursing Assistant and aware of the above findings regarding the current patient records. Preliminary findings regarding the lack of evidence of personal care services being provided by the staff of the Behavioral Health Unit was confirmed with the Facility Representative on 05/09/12 at 1200.