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Based on review of clinical records, interviews and review of hospital policies and procedures for two of ten patients (Patients #3 and 4) that had care and services provided in the emergency department (ED), the hospital failed to ensure that the patient and/or family member understood the discharge plan including post hospital care and/or failed to ensure that the discharge plan was comprehensive and/or that the patient was referred for the appropriate services. The findings include:

1a. Patient #3 arrived at the Emergency Department (ED) on 8/17/10 at 9:43 P.M. via ambulance under a police emergency certificate for suicidal ideation. Patient #3 was diagnosed with alcohol intoxication and anxiety disorder then discharged to home on 8/18/10 at 4:25 A.M. with instructions to remove firearms from the home and lock the firearms up, avoid alcohol and call psychiatry at a listed number to address alcohol issues. Review of the discharge instructions did not reflect documentation regarding a referral for the anxiety disorder and/or contact information for emergent and/or urgent need. Interview with the Medical Director of the ED on 8/27/10 at 9:30 A.M. identified that the referral information which listed a telephone number to address the patient's alcohol issues would also address the patient's anxiety disorder. He/she further identified that the patient could return to ED if he/she had any difficulty and/or felt unsafe and for emergent and urgent help the patient could call 911 and this information was not documented on the discharge instructions. Review of the hospital policy and procedure, titled Discharge From Emergency Department, identified that discharge paperwork will contain a contact number for the hospital Emergency Department.

b. Review of the clinical record did not reflect documentation that the patient and/or family member understood the discharge instructions. Interview with RN #10 on 8/27/10 at 7:40 A.M. identified that he/she discharged Patient #3 to home with a family member and there was no documentation that the patient and/or family member understood the discharge instructions. Interview with the Nurse Manager of the ED on 8/24/10 at 3:04 P.M. and the Medical Director of the ED, on 8/27/10 at 9:30 A.M., identified that there was no documentation that identified that the patient's family understood the discharge instructions. Review of the hospital policy and procedure, titled Discharge From Emergency Department, identified that the patient's response to the discharge instructions is "documented".

c. Review of the clinical record identified that starting at 10:00 P.M., a constant observation (within a staff member's line of sight) was initiated and was continued until 8/18/10 at 3:30 A.M. Interview with the Medical Director of the ED on 8/27/10 at 9:30 A.M. identified that for patients that arrive at the ED with a police emergency certificate for suicidal ideation, the staff monitors the patient. The clinical record did not reflect a physician order for the constant observation.

2. Patient #4 arrived at the hospital ED on 8/16/10 at 3:48 P.M. via ambulance from an assisted living facility with complaints of bizarre behavior, paranoia, auditory and visual hallucinations and a past medical history that included bipolar disorder. Review of the clinical record reflected that Patient #4 was monitored via 1:1 observation (within arms length) at 4:51 P.M.. Review of the clinical record and interview with the Nurse Manager of the ED on 8/24/10 at 2:45 P.M. did not reflect documentation of a physician order for the 1:1 observation.

Interview with the Medical Director of the ED, on 8/27/10 at 9:30 A.M., identified that although a nurse may initiate a 1:1 observation and/or a constant observation (CO), a physician order must be obtained. Although the Care of the Behavioral Patient in the ED Policy directs that constant observation require a written order, the policy doesn't identify a requirement for a physician order on 1:1 observation. The Restraint, 1:1, and CO Flowsheet directs that 1:1 requires a verbal or written order within an hour.

Based on review of clinical records, interviews, review of hospital documentation and review of hospital policies and procedures for six of twelve patients (Patients # 3, 1, 2, 4, 5, and 6) that had behavioral health issues and/or concerns and/or that requested to have a social services referral, the hospital staff failed to ensure that the patient was comprehensively assessed and/or monitored for safety and/or that the referral was completed in accordance with facility policies. The findings include:

1a. Patient #3 arrived at the Emergency Department (ED) on 8/17/10 at 9:43 P.M. via ambulance under a police emergency certificate for suicidal ideation. Review of the clinical record and interview with the Nurse Manager of the ED on 8/24/10 at 3:04 P.M. identified that there was no documentation that the nurse assessed Patient #3 for self-harm, aggression, elopement and/or domestic violence. Review of the hospital policy and procedure, titled Behavioral Patients: Care of the Behavioral Patient in the Emergency Department, identified that at triage the nurse assesses the behavioral patient using the Psycho-Assessment Tool for the following high risk behaviors: active suicidal intent, homicidal intent, aggressive behavior and self-harming behavior and risk of elopement. A second hospital policy and procedure, titled Abuse: Domestic Violence, identified that the nurse will assess the patient for signs and symptoms of domestic violence and indicators of fear and violence to ensure that the patient's safety is maintained while hospitalized, counseling and support offered and the patient will be discharged to a safe environment.

b. Review of the clinical record identified that starting at 10:00 P.M., a constant observation (within a staff member's line of sight) was initiated and was continued until 8/18/10 at 3:30 A.M. Interview with the Medical Director of the ED on 8/27/10 at 9:30 A.M. identified that for patients that arrive at the ED with a police emergency certificate for suicidal ideation, the staff monitors the patient. The clinical record did not reflect a physician order for the constant observation.

Interview with the Medical Director of the ED, on 8/27/10 at 9:30 A.M., identified that although a nurse may initiate a 1:1 observation and/or a constant observation, a physician order must be obtained. Review of the Care of the Behavioral Patient in the ED Policy directs that constant observation require a written order in the ED chart.

c. Review of the clinical record did not reflect that the patient was changed into hospital clothing and/or that the patient's valuable and/or potentially dangerous items were identified and/or removed from the patient in a timely manner. The clinical record reflected that at 10:58 P.M. (one hour and fifteen minutes after arrival), that Patient #3 had a four-inch knife and the knife was turned over to a hospital security/police officer. Interview with the ED Charge Nurse (RN #1) on 8/23/10 at 3:05 P.M. identified that he/she removed a knife from the patient's belongings and a hospital officer secured the knife. Interview with the Nurse Manager of the ED on 8/24/10 at 3:04 P.M. identified that for a patient that arrives at the ED with behavioral health issues/concerns, the staff is to change him/her into hospital clothing and search the belongings as soon as possible. Review of the hospital police department documentation dated 8/17/10 at 10:56 P.M. identified that the ED Charge Nurse informed Officer #1 at 11:56 P.M. that Patient #3 had a knife and Officer #1 removed the knife. Review of the hospital policy and procedure, titled Behavioral Patients: Care of the Behavioral Patient in the Emergency Department, identified that all patients that have behavioral health issues will be changed into hospital clothing and clothing, valuables, medications and potentially dangerous equipment/items are removed from the room after an assessing for high-risk behaviors. A second hospital policy and procedure titled Searching Patient's Personal Possessions identified that the hospital staff may conduct a search of the patient's belongings for patient and/or staff safety if the safety of the staff/patient may be comprimised and/or if the patient is suspected of possessing substances/contraband which may interfere with diagnostic or therpeutic interventions.

d. Patient #3 was diagnosed with alcohol intoxication and anxiety disorder then discharged to home on 8/18/10 at 4:25 A.M. with instructions to remove firearms from the home and lock the firearms up, avoid alcohol and call psychiatry at a listed number to address his/her alcohol issues. Review of the clinical record and interviews with RN #10 and with the Nurse Manager of the ED on 8/27/10 at 7:40 A.M. and on 8/24/10 at 3:04 P.M. respectively, did not reflect documentation that the patient and/or family member understood the discharge instructions. In addition, the clinical record failed to identify who the patient was discharged with. Review of the hospital policy and procedure, titled Discharge From Emergency Department, identified that the patient's response to the discharge instructions is documented.

2a. Patient #1 arrived at the hospital ED on 8/22/10 at 3:16 P.M. via ambulance from a group home with "acting out " behaviors and a past medical history that included hypoglycemia, new onset seizures, attachment disorder with anxiety, depression, psychosis, self-injurious and manipulative behaviors and mental retardation. Review of the clinical record and interview with the Nurse Manager of the ED on 8/27/10 at 11:20 A.M. identified that there was no documentation that the nurse assessed Patient #1 for self-harm, aggression and/or elopement. Review of the hospital policy and procedure, titled Behavioral Patients: Care of the Behavioral Patient in the Emergency Department, identified that at triage the nurse assesses the behavioral patient using the Psycho-Assessment Tool for the following high risk behaviors: active suicidal intent, homicidal intent, aggressive behavior and self-harming behavior and risk of elopement.
In addition, documentation dated 8/22/10 at 3:35 P.M. by RN #1, reflected that Patient #1 verbalized that the group home staff was hitting him/her and RN #1 documented that domestic violence section of the clinical record was not applicable and/or that the patient was provided counseling or support. Interview with RN #1, on 8/24/10 at 10:28 A.M., identified that when a patient communicated that he/she was hit, RN #1 did not identify that the patient had experienced "domestic violence". Review of the hospital policy and procedure, titled Abuse: Domestic Violence, identified that the nurse will assess the patient for signs and symptoms of domestic violence and indicators of fear and violence to ensure that the patient's safety is maintained while hospitalized, counseling and support offered and the patient will be discharged to a safe environment.

b. Review of the clinical record and interview with the Nurse Manager of the ED on 8/27/10 at 11:20 A.M., failed to reflect documentation that the staff obtained Patient # 1's vital signs including blood pressure, heart rate, respiratory rate and temperature, on admission. Review of the hospital policy and procedure, titled Triage: Care of the Patients in, identified that vital signs are completed including assessment of the patient's level of pain.

c. Patient #1's medical history documentation included new onset seizures. Review of Patient #1's clinical record and observation of care, with the ED Nurse Manager on 8/23/10 at 11:45 A.M., failed to reflect documentation that the staff assessed the patient for a seizure history and/or that seizure precautions were in place for Patient #1. Interview with RN #2, on 8/23/10, identified that he/she was the nurse assigned to care for Patient #1 and he/she was not aware if the patient had a medical history of seizures. Review of the hospital policy and procedure, titled Seizures: care of the Patient at Risk and Actual, identified that on admission patients will be assessed for a seizure history and if positive will be placed on seizure precautions.

d. Review of the clinical record did not reflect documentation that a diet was ordered for Patient #1 and/or that the patient was provided with a meal tray at dinner although the record contained information from the patient ' s group home regarding a specialized diet that the patient required, (a 1700 calorie American Diabetic Association diet, low fat and cholesterol, no concentrated sweets and low simple carbohydrates). In addition, documentation reflected that on 8/22/10 at 11:44 P.M., RN #13 performed a blood glucose test and the result was 62 milligrams per deciliter (mg/dl, hospital normal identified as 75 to 200mg/dl) and the patient was given orange juice. Review of he clinical record did not reflect documentation that the patient was assessed for signs and symptoms of recurrent hypoglycemia. Interview with the ED Nurse Manager, on 8/27/10 at 11:20 A.M., identified that there was no documentation of a physician order for a diet for this patient and/or that the nurse completed any further assessment of this patient regarding hypoglycemia including completing a second blood glucose test.
In addition, on 8/23/10 at 6:33 A.M. documentation reflected that Patient #1 complained of feeling weak RN #14 performed a blood glucose test and the result was 68 mg/dl and the patient was given juice and crackers. On 8/23/10 at 8:01 A.M. documentation reflected that RN #2 gave Patient #1 a meal tray and the patient ate 50% of that meal. Interview with RN#2, on 8/23/10, identified that he/she asked the patient what type of meal that he/she wanted, RN #2 ordered what the patient wanted and RN #2 was not aware if Patient #1 had a diagnosis of hypoglycemia. Review of the hospital policy and procedure, titled Hypoglycemia Reaction: Acute (Adult), the nurse monitors the patient for signs and symptoms of recurrent hypoglycemia and may repeat a blood glucose test.
Interview with the Director of Food Services, on 8/24/10 at 9:32 A.M., identified that for patients in the ED the food services department provides diets according to orders placed via telephone call from ED staff and there is no verification in place to ensure that a physician has ordered the diet and/or that the diet is appropriate for each patient. Subsequent to inquiry the Director of Food Services identified a new process of entering and confirming diet orders for the ED including the physician will complete a diet order and that order will be faxed to the food services department prior to the meal delivery to a patient.

3a. Patient #2 arrived at the hospital ED on 8/22/10 at 8:41 P.M. with the complaints of feeling nervous and distracted for one day, auditory hallucinations, disorganized behavior, paranoid ideations and ideas of reference for several days and past medical history of bipolar disorder. Review of the clinical record and interview with the Nurse Manager of the ED on 8/24/10 at 2:25 P.M. identified that there was no documentation that the nurse assessed Patient #2 for self-harm, aggression and/or fall risk. Review of the hospital policy and procedure, titled Behavioral Patients: Care of the Behavioral Patient in the Emergency Department, identified that at triage the nurse assesses the behavioral patient using the Psycho-Assessment Tool for the following high risk behaviors: active suicidal intent, homicidal intent, aggressive behavior and self-harming behavior and risk of elopement.

b. Review of the clinical record did not reflect documentation that the patient was changed into hospital clothing and/or that the patient's valuable and/or potentially dangerous items were identified and/or removed from the patient in a timely manner. Documentation, dated 8/23/10 at 7:28 A.M. (11 hours and 47 minutes after admission) reflected that Patient #2's belongings were removed and documentation did not reflect when the patient changed into hospital clothing. Interview with the Nurse Manager of the ED on 8/24/10 at 2:25 P.M. identified that he/she did not know why there was a delay in removing the belongings of this patient. A second interview with the Nurse Manager of the ED on 8/24/10 at 3:04 P.M. identified that for a patient that arrives to the ED with behavioral health issues/concerns, the staff is to change him/her into hospital clothing and search the belongings as soon as possible.
Review of the hospital policy and procedure, titled Behavioral Patients: Care of the Behavioral Patient in the Emergency Department, identified that all patients that have behavioral health issues will be changed into hospital clothing and clothing, valuables, medications and potentially dangerous equipment/items are removed from the room after an assessing for high-risk behaviors.

c. Review of the clinical record, dated 8/23/10 at 7:30 A.M., 8:02 A.M. and 11:29 A.M., reflected Patient #2 was given a meal tray, ate 80% of the meal and a lunch tray was ordered although review of the clinical record did not reflect documentation that a physician ordered a diet for this patient. Interview with the ED Nurse Manager, on 8/24/10 at 2:25 P.M., identified that there was no physician order for a diet for this patient.
Interview with the Director of Food Services, on 8/24/10 at 9:32 A.M., identified that for patients in the ED the food services department provides diets according to orders placed via telephone call from ED staff and there is no verification in place to ensure that a physician has ordered the diet and/or that the diet is appropriate for each patient. Subsequent to inquiry the Director of Food Services identified a new process of entering and confirming diet orders for the ED including the physician will complete a diet order and that order will be faxed to the food services department prior to the meal delivery to a patient.

4a. Patient #4 arrived at the hospital ED on 8/16/10 at 3:48 P.M. via ambulance from an assisted living facility with complaints of bizarre behavior, paranoia, auditory and visual hallucinations and a past medical history that included bipolar disorder. Review of the clinical record and interview with the Nurse Manager of the ED on 8/24/10 at 2:45 P.M. identified that there was no documentation that the nurse assessed Patient #4 for suicidal intent, homicidal intent, self-harm, aggression, elopement. Review of the hospital policy and procedure, titled Behavioral Patients: Care of the Behavioral Patient in the Emergency Department, identified that at triage the nurse assesses the behavioral patient using the Psycho-Assessment Tool for the following high risk behaviors: active suicidal intent, homicidal intent, aggressive behavior and self-harming behavior and risk of elopement.

b. Review of the clinical record and interview with the Nurse Manager of the ED on 8/24/10 at 2:45 P.M., failed to reflect documentation that the staff obtained Patient #4's vital signs including blood pressure, heart rate, respiratory rate and temperature, on admission. Review of the hospital policy and procedure, titled Triage: Care of the Patients in, identified that vital signs are completed including assessment of the patient's level of pain.

c. Review of the clinical record did not reflect documentation that the patient was changed into hospital clothing and/or that the patient's valuables were checked in a timely manner. Documentation reflected that on 8/16/10 at 7:48 P.M. (4 hours after arrival) Patient #4's belongings were removed and at 8:34 P.M. (4 hours and 46 minutes after arrival) the patient changed into hospital clothing. Interviews with the Nurse Manager of the ED on 8/24/10 at 2:45 P.M. and at 3:04 P.M. identified that he/she could not explain the delay in changing Patient #4 into hospital clothing and/or removing personal belongings and for a patient that arrives in the ED with behavioral health issues/concerns, the staff is to change him/her into hospital clothing and search the belongings as soon as possible. Review of the hospital policy and procedure, titled Behavioral Patients: Care of the Behavioral Patient in the Emergency Department, identified that all patients that have behavioral health issues will be changed into hospital clothing and clothing, valuables, medications and potentially dangerous equipment/items are removed from the room after an assessing for high-risk behaviors.

d. Review of the clinical record identified that the staff administered Ativan 2 milligrams (mg) via intramuscular injection on 8/16/10 at 7:45 P.M. per order by MD #7. Interview with MD #7, on 8/27/10 at 2:40 P.M., identified that he/she prescribed the Ativan for Patient #4 due to the patient's level of agitation. Review of the clinical record did not reflect a re-assessment of the patient's level of agitation after the administration of medication.

5a. Patient #5 arrived at the hospital ED on 8/16/10 at 2:29 P.M. with a family member with complaints of increased depression, not taking medications for past month and a past medical history that included Diabetes Mellitus, depression and past suicide attempts. Review of the clinical record and interview with the Nurse Manager of the ED on 8/24/10 at 2:35 P.M. identified that there was no documentation that the nurse assessed Patient #5 for suicidal intent, homicidal intent, self-harm, aggression and/or elopement. Review of the hospital policy and procedure, titled Behavioral Patients: Care of the Behavioral Patient in the Emergency Department, identified that at triage the nurse assesses the behavioral patient using the Psycho-Assessment Tool for the following high risk behaviors: active suicidal intent, homicidal intent, aggressive behavior and self-harming behavior and risk of elopement.

b. Review of the clinical record did not reflect documentation that the patient was changed into hospital clothing and/or that the patient's valuables and/or potentially dangerous items were identified and/or removed from the patient in a timely manner. Documentation reflected that on 8/16/10 at 4:56 P.M. (2 hours and 26 minutes after arrival) Patient #5's was changed in hospital clothing and on 8/17/10 ay 12:12 A.M. Patient #5's belongings were removed (9 hours and 43 minutes after arrival).
Interviews with the Nurse Manager of the ED on 8/24/10 at 3:04 P.M. identified that removing personal belongings and for a patient that arrives to the ED with behavioral health issues/concerns, the staff is to change him/her into hospital clothing and search the belongings as soon as possible. Review of the hospital policy and procedure, titled Behavioral Patients: Care of the Behavioral Patient in the Emergency Department, identified that all patients that have behavioral health issues will be changed into hospital clothing and clothing, valuables, medications and potentially dangerous equipment/items are removed from the room after an assessing for high-risk behaviors.

c. In addition, review of the clinical record did not reflect that Patient #5 had a diet ordered and/or was assessed regarding his/her Diabetes Mellitus although documentation, dated 8/17/10 at 12:12 A.M./ reflected that the patient was offered a meal but refused. Patient #5 was transported to the inpatient unit on 8/17/10 at 12:49 A.M. Interview with the Nurse Manager of the ED on 8/24/10 at 2:35 P.M. identified that there was no documentation of a physician order for a diet.
Interview with the Director of Food Services, on 8/24/10 at 9:32 A.M., identified that for patients in the ED the food services department provides diets according to orders placed via telephone call from ED staff and there is no verification in place to ensure that a physician has ordered the diet and/or that the diet is appropriate for each patient. Subsequent to inquiry the Director of Food Services identified a new process of entering and confirming diet orders for the ED including the physician will complete a diet order and that order will be faxed to the food services department prior to the meal delivery to a patient.

d. Review of the clinical record identified that the staff administered Benadryl 50 milligrams (mg) by mouth on 8/16/10 at 6:23 P.M. and Ativan 2 mg by mouth on 8/16/10 at 7:43 P.M. per order by MD #6. Review of the clinical record did not reflect a re-assessment of the patient's status after the administration of these medications.

6a. Patient #6 arrived at the hospital ED on 8/19/10 at 1:42 P.M. with complaints of reaction to the medication Trileptal including photosensitivity and rash. In addition, documentation at 2:24 P.M. reflected that the patient reported suicidal ideation and had a plan to cut his/her wrists. Interview with the Nurse Manager of the ED, on 8/24/10 at 2:55 P.M. and documentation reflected that the patient was maintained on a constant observation (within a staff member's line of sight) on 8/19/10 from 3:15 P.M. until 8:15 P.M. and the record lacked documentation of a physician order for the constant observation. Review of the Care of the Behavioral Patient in the ED Policy directs that constant observation requires a written order in the ED chart.

b. Documentation dated 8/19/10 at 4:52 P.M., identified that the ED staff gave Patient #6 a meal tray and documentation did not reflect that there was a physician order for a particular diet and/or the type of meal tray that was provided and/or the amount of the meal tray that the patient consumed. Interview with the Director of Food Services, on 8/24/10 at 9:32 A.M., identified that for patients in the ED the food services department provides diets according to orders placed via telephone call from ED staff and there is no verification in place to ensure that a physician has ordered the diet and/or that the diet is appropriate for each patient. Subsequent to inquiry the Director of Food Services identified a new process of entering and confirming diet orders for the ED including the physician will complete a diet order and that order will be faxed to the food services department prior to the meal delivery to a patient.

On 9/2/10, the Department requested an action plan to address issues related to behavioral health patient assessments and documentation of belongings for ED patients. The Hospital submitted a plan that included a review of current policies and procedures on assigning level of care, review of policies related to level of care to ensure that all patients are assessed using the same behavioral criteria, monitoring of staff during daily patient rounding, education staff on documenting the accurate time that valuables have been removed from the patient, an educational plan on levels of observation, and a monitoring plan.

Based on review of clinical records, interviews and hospital policies and procedures for four of twelve patients (Patients #3, 7, 10, 11) that had care and services provided by the hospital, the hospital failed to ensure that the clinical record was accurate and/or complete. The findings include:

1a.Patient #3 arrived at the Emergency Department (ED) on 8/17/10 at 9:43 P.M. via ambulance under a police emergency certificate for suicidal ideation. The Daily Observation Plan dated 8/17/10 at 10:00 P.M. identified that medication was an alternative attempted prior to the inititation of constant observation. Review of the clinical record did not reflect documentation that any medication was ordered and/or administered to Patient #3 prior to the initiation of the constant observation. Review of the hospital policy and procedure Care of the Patient in the ED directed to administer medications for agitation per MD only. Assess patients for signs and symptoms of alcohol/drug withdrawal and treat appropriately. In addition, documentation reflected that the staff provided constant observation (within a staff member's line of sight) of Patient #3 from 8/17/10 at 10:00 P.M. to 8/18/10 at 3:30 A.M. and documentation did not reflect the rationale for the discontinuation of observation.

b. Review of the clinical record, dated 8/17/10 at 11:12 P.M. identified that Patient #3's ethanol level was 170 milligrams per deciliter (mg/dl, with intoxication 100 mg/dl or greater). The Initial Suicide Risk Screening completed by Social Worker #1 dated 8/17/10 at 11:35 P.M. (23 minutes later) identified that Patient #3 was not currently intoxicated. Although the patient had an elevated blood alcohol level, the Initial Suicide Risk Screening inaccurately identified that the patient was not currently intoxicated.

2. Patient #7 arrived at the hospital ED on 8/21/10 at 6:16 P.M. via ambulance with the complaints of vomiting, diaphoresis and history of recent alcohol intake. Review of the clinical record identified that the patient was diagnosed with alcohol intoxication and received 450 milliliters (ml) of some type (type not documented) of intravenous fluids while in the ED. Review of the clinical record and interview with the Nurse Manager of the ED, on 8/24/10 at 3:00 P.M., identified that there was no physician order that directed the staff to administer intravenous fluids to the patient and the patient received 450 ml of intravenous fluid.

3. Patient #10 arrived at the hospital ED on 7/22/10 with a police emergency certificate from a group home due to the patient's increased level of agitation and/or patient report of hearing voices with a past medical history of schizoaffective disorder, bipolar disorder, obsessive compulsive disorder and eating disorder. Patient #10 was diagnosed with decompensation of his/her psychotic symptoms and was admitted to the hospital. Review of the clinical record, dated 8/25/10 at 9:00 P.M., reflected that Patient #10 was displaying signs of anxiety and RN #1 administered Haldol 5 milligrams (mg), Ativan 2 mg and Cogentin1 mg at 4:00 P.M. and at 4:45 P.M. The record did not reflect documentation of the route of the medications and/or the patient's response to the 4:45 P.M. medications. Interview with the Nurse Manager of the Behavioral Health unit, on 8/26/10 at 11:20 A.M., identified that there was no route documented for the identified medications and/or no patient response documented for the 4:45 P.M. medications. In addition, he/she added that according to the Medication Administration record those medications were administered at 6:36 P.M. and 9:33 P.M.

4. Patient #11 was admitted to the hospital on 8/6/10. Tour of the unit, on 8/26/10 from 8:45 A.M. to 9:45 A.M. identified that Certified Nursing Assistant (patient care assistant) #2 was observing Patient #11 for a 1:1 observation. Review of the observation plan for Patient #11 identified that it was dated 8/25/10 at 7:00A.M., more than 24 hours earlier. The patient was to receive nothing by mouth in order to prepare for electroconvulsive therapy (ECT). Interview with Certified Nursing Assistant #2, on 8/26/10, identified that he/she was observing Patient for 1:1 observation, he/she had delivered a meal to the patient earlier and a the start of the shift he/she received a verbal report from the previous staff observer and the Registered Nurse who was assigned to Patient #11. Staff failed to hold the patient's tray in accordance with the plan of care. Review of the hospital policy and procedure, titled 1:1 Observation/Constant Observation: Monitoring of Acute Medical/Surgical and/or Behavioral Health Patients, identified that 1:1 observation is a high level observation for safety, and the patient's nurse completes the observation plan daily and will review the plan with the staff observer.

Based on review of the clinical record, interviews, review of hospital documentation and review of hospital policy and procedure for one patient (Patient #3) that arrived at the hospital on a police emergency certificate and was discharged, the hospital failed to ensure that the patient and/or family member understood the discharge plan including post hospital care and/or that the hospital failed to ensure that the patient was referred to the appropriate services and/or was provided contact information for emergent and/or urgent need. The findings include:

1a. Patient #3 arrived at the Emergency Department (ED) on 8/17/10 at 9:43 P.M. via ambulance under a police emergency certificate for suicidal ideation. Patient #3 was diagnosed with alcohol intoxication and anxiety disorder then discharged to home on 8/18/10 at 4:25 A.M. with instructions to remove firearms from the home and lock the firearms up, avoid alcohol and call psychiatry at a listed number to address alcohol issues. Review of the discharge instructions did not reflect documentation regarding a referral for the anxiety disorder and/or contact information for emergent and/or urgent need. Interview with the Medical Director of the ED on 8/27/10 at 9:30 A.M. identified that the referral information listed a telephone number to address the patient's alcohol issues would also address the patient's anxiety disorder, the patient could return to ED if he/she had any difficulty and/or felt unsafe and for emergent and urgent help the patient could call 911 and this information was not documented on the discharge instructions. Review of the hospital policy and procedure, titled Discharge From Emergency Department, identified that discharge paperwork will contain a contact number for the hospital Emergency Department.

b. Review of the clinical record did not reflect documentation that the patient and/or family member understood the discharge instructions. Interview with RN #10 on 8/27/10 at 7:40 A.M. identified that he/she discharged Patient #3 to home with a family member and there was no documentation that the patient and/or family member understood the discharge instructions. Interviews with the Nurse Manager of the ED on 8/24/10 at 3:04 P.M. and the Medical Director of the ED on 8/27/10 at 9:30 A.M. identified that there was no documentation that the patient understood the discharge instructions. Interview with the identified that there was no documentation that identified that the patient's family understood the discharge instructions. Review of the hospital policy and procedure, titled Discharge From Emergency Department, identified that the patient's response to the discharge instructions is documented.