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Based on observation, interview and record review the facility failed to provide a care or treatment plan for a significant behavioral/health problem for 1 (#6) of 7 patients. Findings include:

On 1/20/11 from 1145-1215, patient #6 was observed refusing to eat lunch. On 1/20/11 at 1215 review of patient #6's clinical record revealed no care or treatment plan for food or medication refusals. Patient #6's record reveal a 1/13/11/physician progress note indicating a diagnosis of bursitis with infection and a physician's order for an antibiotic (Keflex, 500 milligrams every 6 hours for 7 days.) Patient refusals of medications, including Keflex, were documented daily from 1/13/11-1/20/11. A Physical Admission Assessment by the Physician, dated 1/12/11 states: " He has been eating inconsistently." A 1/12/11 note by the Registered Dietitian states: "Inadequate oral food /beverage intake ...noncompliance with meds, refusal to eat, known dysphagia history." Meal intake worksheets indicate that patient #6 refused all 3 meals on1/16/11, 1/18/11 and 1/19/11 and ate only ? sandwich on 1/15/11.

On 1/20/11 at approximately 1600 the Chief Nursing Officer verified that patient #6's clinical record contained no care or treatment plan for medication or food refusals. The facility was unable to provide a policy indicating whether frequent food and medication refusals would warrant a care plan or treatment plan documentation.

Based on observation, interview and policy review, the facility failed to prepare and administer medications using acceptable standards of practice for 4 of 5 patients (#2, #3, #4, #6) reviewed. Findings include:
During observation on the Older Adult Program (OAP) unit on 01/19/2011 at 0900, staff #4 was observed setting up medications for patients. Review of the medication cart revealed that a drawer labeled as 507-1 (patient #2) contained a paper medication cup labeled with only the medication name " Loscol. " Another drawer labeled as room 508-2 (patient #4) contained a paper medication cup with 8 pills and no information was written on the cup. Drawer labeled as 505-2 (patient #3) contained a small 1ml unpackaged syringe with a liquid inside and no information available on the syringe. Staff #4 was queried at this time about the findings in the drawers of the med cart and she replied that the syringe contained Risperdal and did not know why it did not have a label on it. She stated that the medication cup found in the drawer labeled 508-2 contained " 2 Potassium, 5 Trilithany and 1 Cogentin that I was going to give to the patient shortly. "
Review of policy titled Medication Administration effective date 9/2010 under section D #9 reads " All medications that are not in the pharmacy packaging or in their original containers must be labeled with the medication and the dose of medication in the container. Opened packages and partial doses are discarded if not administered. All medications are to be accurately labeled with an expiration date and disposed of when expired. "

Based on record review interview, the facility failed to ensure that therapeutic diets are followed as ordered by the physician for 1 of 1 (#8) patients reviewed. Findings include:
Review of the medical record for patient #8 revealed that the physician ordered a 2000 calorie American Diabetic Association (ADA) diet. Interview with the Registered Dietician on 01/20/11 at 1500, she was queried as to how staff are aware of what a patient is to receive at each meal if they have a 2000 calorie ADA diet ordered. She replied that they do not follow the diet ordered by the physician but instead use a plan called the Basal dosing. Insulin is administered based on how many carbohydrates the patient eats.
When queried further if this dietary plan was part of the approved dietary manual used she stated that " there is not an approved diet manual " and went on to say that she has a " verbal OK by from the physician ' s to use this method. "

Based on observation, interview and record review, the facility failed to provide a dietary manual that had been approved by a Registered Dietitian and the Medical staff. Findings include:

On 1/20/11 at approximately 1400, the facility's dietary manual was reviewed with the Registered Dietitian (RD). The RD was asked to provide evidence that the manual had been approved by a Registered Dietitan and the Medical staff. The RD stated that she was unable to provide documentation of approvals by either as this was not their practice.