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Based on interview and record review the hospital failed to ensure RN's (Registered Nurses) supervised and evaluated the nursing care for 1 of 10 patients (Patient #1's) medical needs. (Patient #1's) B/P (blood pressure), HR (heart rate) and change of condition was either not documented and/or (Patient #1's) vital signs were not re-evaluated by hospital RN's assigned to care for (Patient #1).

Findings included:

(Patient #1's) Clinical assessment dated 01/16/13 timed at 03:25 PM reflected, "Haven't been sleeping...try not to be on drugs...smoking a lot of synthetic stuff...not been bathing...not been rational lately...paranoid laughs inappropriately...B/P (blood pressure) 148/92...pulse 101...substance abuse history...marijuana daily...synthetic marijuana almost daily...periods of sobriety months ago..."

The Patient Rounds Progress Note/15 Minute Patient Rounds document for B/P (blood pressure) and heart rate from 01/18/13 through 01/29/13 reflected the following:

The 01/18/13 progress note timed at 09:02 AM reflected, "B/P 143/99, HR (Heart Rate) 109." No follow-up documentation was found which indicated (Patient #1's) heart rate and blood pressure were re-checked.

The 01/22/13 progress note timed at 08:29 AM reflected, "B/P 80/57, HR 119." No B/P re-check was completed for the above and no documentation was found which indicated the nurse provided intervention and/or (Patient #1's) vital signs were re-checked.

The 01/23/13 progress note timed at 09:00 AM reflected, "B/P 143/100, HR 110." No follow-up and/or re-check was completed for the above and no documentation was found which indicated the nurse provided intervention and/or (Patient #1's) vital signs were re-checked.

The 01/25/13 progress note timed at 09:16 AM reflected, "B/P 140/103, HR 119." No follow-up and/or re-check was documented for (Patient #1's) elevated B/P or elevated heart rate.

The 01/28/13 progress note reflected no documentation which indicated (Patient #1's) vital signs were obtained.

The 01/29/13 progress note timed at 17:00 PM reflected, "Patient outside smoking, became dizzy, dropped cigarette...nurse notified." No nursing assessment and/or documentation was found which indicated the above event was addressed and/or evidence (Patient #1's) vital signs were obtained.

The Patient Data/Assessment/Treatment Process document dated 01/30/13 through 02/01/13 reflected the following:

The 01/30/13 Patient Data document timed at 16:40 PM reflected under the section entitled, "Gastrointestinal...vomited times one during smoke break...no food content, encouraged to eat..." No further documentation intervention/assessment of vital signs was completed.

The 02/01/13 Patient Data document timed at 07:00 AM reflected, "Complained of being drowsy majority of shift and stayed in bed..." No further assessment/documentation was found for the above event.

The Patient Rounds/progress note reflected, "Document significant behavior events and/or unusual incidents for patient...normal ranges B/P 100/80-140/90...pulse...60-100...notify nurse if any vitals are out of normal range..."

On 02/22/13 at approximately 10:45 AM Personnel #6 was interviewed. Personnel #6 reviewed the Patient Data Documents and the Patient Rounds Progress Note/15 Minute Patient Rounds document from 01/18/13 through 02/01/13. Personnel #6 stated nursing did not document and/or reassess (Patient #1) for the above out of range vital signs and events.

Based on interview and record review the hospital failed to ensure one of one patient (Patient #1) received medication in accordance with physician orders in that nursing staff administered Ibuprofen without a physician order on 02/02/13.

Findings included:

(Patient #1's) discharge summary dated 02/05/13 and signed by Personnel #8 noted (Patient #1's) final diagnoses included Bipolar disorder with Psychotic Features, K2 and Marijuana Abuse, Hypertension, Possible Seizure or Respiratory Failure.

The Medication Administration Record (MAR) dated 02/02/13 at 12 AM through 02/02/13 at 11:59 PM reflected, "Ibuprofen 600 milligrams (mg) by mouth every six hours when necessary for pain." Ibuprofen 600 milligrams was documented as administered on 02/02/13 at 10:30 AM.

The Physician Orders dated 01/16/13 through 02/02/13 did not reflect an order for Ibuprofen 600 mg by mouth every six hours when necessary for pain.

During an interview on 02/22/13 at 1:35 PM Personnel #6 stated there was no order for Ibuprofen written for (Patient #1).