HospitalInspections.org

Based on policies and procedures, practice standards, observation and interview, it was determined the facility failed to ensure:

1. Glucometer control monitoring and performance tests were completed and documented according to facility policy

2. Emergency medication cart (crash cart) monitoring and documentation was completed according to facility policy

3. Facility emergency medication Sodium Bicarbonate dosage available was appropriate for children and adolescent patients served by the facility

This had the potential to affect all patients served by the facility.

Findings include:

Policy: 900.413
Manual: Nursing
Title: Crash Cart Maintenance
Review Date 8/5/12

Purpose:
To standardize the Crash Cart so that equipment and supplies ...are consistent and appropriate.

Nursing Staff
"1. At the beginning of each shift, the shift (staff) performs and documents the following on the crash cart
...b. Assures all medications and supplies are not expired.
c. Assures AED (automatic external defibrillator) is present and AED pads are not expired.
...e. Assures AED powers up.
f. Documents follow up for "No" response on log.
g. Signs log...and initial the am or pm box."

"...Dates of expiration of drugs and materials are to be recorded by the unit staff on the Crash Cart Log..."


Policy: 900.404
Manual: Nursing
Title: Blood Glucose Testing (Waived Testing)
Revision Date 7/23/12

"...Controls/Performance Checks
2. The RN (Registered Nurse)/LPN (Licensed Practical Nurse) should run a performance test nightly on the meter...
4. Control tests should be performed by the RN/LPN...and weekly on the night shift...
6. Document performance checks and glucose meter controls on the Glucometer Check Log. The expected range for the controls should be documented on the log.


Mosby's 2013 Nursing Drug Reference, 26th Edition
Page 1086
Sodium Bicarbonate (prescription), OTC (over the counter)
Action...reverses acidosis IV (Intravenous)
Uses: Acidosis (metabolic), cardiac arrest...
Dosage and Routes
Acidosis, metabolic...
Cardiac arrest
Adult and child: IV BOL (bolus) 1 mEq (milliequivalent)/kg (kilogram) of 7.5 % (percent) or 8.4 % solution (sol), then 0.5 mEq/kg q (every) 10 minutes, then doses based on arterial blood gases
Infant: IV 1 mEq/kg over several minutes (use only the 0.5 mEq/ml (milliliters) [4.2 %] sol for inj (injection)...


On 10/22/13 at 10:35 AM, the surveyor observed a CLIA (Clinical Laboratory Improvement Amendment) Waiver certificate in the medication (med) dispensing room. Employee Identifier (EI) # 4, LPN, med nurse reported to the surveyor the facility performed glucose monitoring per physician orders using the facility glucometer.

EI # 4 reported to the surveyor the night nurse does weekly control monitoring and documents the results on a log.

Review of a white binder located in the med room included the facility's glucometer policy and a "Glucometer Checks" log document.

Review of the September and October 2013 "Glucometer Checks" log provided to the surveyor revealed staff failed to perform and document glucometer meter performance tests nightly as per policy.

The following dates in September 2013 were left blank under the "Glucometer Checks" log "Performance" column: 9/6/13, 9/9/13, 9/10/13, 9/13/13, 9/14/13, 9/15/13, 9/20/13, 9/23/13, 9/24/13, 9/27/13, 9/28/13, 9/29/13 and 9/30/13.

Review of the October 2013 "Glucometer Checks" log "Performance" column failed to reveal documentation nightly test performance was completed the following dates: 10/1/13, 10/2/13, 10/3/13, 10/4/13, 10/7/13, 10/11/13, 10/12/13, 10/14/13, 10/15/13, 10/16/13, 10/17/13, 10/18/13, 10/19/13, 10/21/13, 10/22/13, 10/23/13 and 10/24/13.

Review of the September and October 2013 "Glucometer Checks" log revealed the facility failed to perform and document weekly glucose meter controls on the following weeks: 9/15/13 to 9/21/13, 9/22/13 to 9/28/13 and 10/13/13 to 10/19/13.

Further review revealed the expected range for the controls were not documented on the log according to facility Policy Number 900.404 Blood Glucose Testing for following weeks: 9/1/13 to 9/7/13, 9/15/13 to 9/21/13, 9/23/13 to 9/28/13, 9/29/13 to 10/5/13, 10/6/13 to 10/13/13 and 10/14/13 to 10/19/13.

An interview with EI # 4, the LPN, on 10/22/13 at 10:40 AM verified staff failed to perform and document the expected control ranges weekly on the glucometer log except on 9/11/13. EI # 4 verified nightly performance tests, weekly glucometer control monitoring and documentation of expected range of controls had not been performed according to facility policy.

The facility failed to follow policy and procedure for use of the glucometer.

On 10/22/13 at 11:00 AM, the surveyor inspected the facility Emergency (ER) Cart with EI # 4. The surveyor observed two boxes of Infant Sodium Bicarbonate (Bicarb) 4.2 % 5 meq (0.5 meq/ml) injectable were found in the facility crash cart. The Sodium Bicarbonate dosing was not adequate for the treatment of children and adolescents ages 10 through 18 served by the facility.

Review of Beacon Children's Hospital Crash Cart Checklist document revealed crash cart maintenance every shift was not performed for the following weeks: 9/4/13, 9/16/13, 9/18/13, 10/7/13, 10/15/13, 10/16/13 and 10/18/13. The date AED pads expire and expiration date of contents were left blank on the 2013 September and October crash cart log checklist.

An interview was conducted with EI # 4 following inspection of the crash cart and review of facility policy. EI # 4 reported she was not aware the Sodium Bicarbonate was for infants and the crash cart maintenance was not being performed and documented according to facility policy.

Based on record review, tour of the facility, review of policies and procedures and an interview, the hospital failed to:

1. Follow their policy for restraint and seclusion and time-outs.

2. Document appropriate use of restraint and seclusion.

3. Document why patients remained in time out for extended periods of time and what treatment was provided while they remained isolated in time out.

4. Document specific orders for restraint and seclusion.


This had the potential to affect all patients in the facility.

Findings include:

Refer to A 154 and A 168 for findings.

Based on review of medical records, review of policy and procedures and interview it was determined the facility failed:

1. To follow facility policy and procedures for use of time-outs.

2. To document in the medical record information regarding the conditions under which the time out occurred.

3. To document why patients remained in time out for extended periods of time and what treatment was provided while they remained isolated in time out.

This had the potential to affect all patients in the facility and did affect Medical Record (MR) # 2, # 3, # 5 and # 6.

Findings include:

Policy # A100.309 Time Out

I. Definitions:

A. Clinical Time-Out- A procedure in which an individual, in voluntary response to verbal direction from staff, cooperatively enters and remains in a designated area from which egress is not blocked for a period of time, not to exceed thirty (30) minutes without specific joint re-determination by the individual and staff of the need for continuation of the procedure.

II. Policy:

A. Clinical time-out may be used as a preventive and de-escalating intervention to preclude the necessity for the emergency use of restraint or seclusion.

B. Clinical Time-Out:

1. Clinical time-out may be initiated by staff but require the individual's cooperation.

2. Time-out may be used as an ongoing behavioral treatment option provided it is documented on the patient's treatment plan along with specific identified behaviors for which it is used.

4. Each use of clinical time-out must be documented in the individual's record with information regarding the conditions (variant behavior) under which the time out occurred.

B. Clinical time out may not be used:

1. as punishment;
2. for the purpose of convenience of staff or other individuals; or
3. as a substitute for effective treatment.


Medical Record (MR) findings:


1. MR # 6 was admitted to the facility 9/4/13 with diagnoses of Bipolar Disorder, Substance Abuse and ADHD (Attention Deficit Hyperactivity Disorder).

On 9/14/13 the Multidisciplinary Notes documented by the Registered Nurse (RN) at 9:15 PM ," Pt (patient) insisted to go into seclusion room and when told there was not staff at this time to sit with him he continued to make threatening statements and refused to walk away from one of the locked doors that he recently kicked in. Another staff member was able to speak with pt and have him move a chair close to the recreation room where staff could monitor closely."

The Close Observation Flowsheet dated 9/14/13 at 7:30 PM through 9:30 PM the patient was in time out at the nurses station.

This exceeded the policy recommended time out of 30 minutes and did not provide the patient privacy to try to calm himself.

The interdisciplinary treatment plan included the use of voluntary time outs to assist with management of his moods and behaviors. The staff failed to follow the treatment plan for MR # 6, stating they did not have enough staff to sit with him.

In an interview 10/24/13 at 9:12 AM with Employee Identifier # 1, the Director of Nursing confirmed the information.

2. MR # 2 was admitted to the facility 10/9/13 with diagnoses of Conduct Disorder, Oppositional Defiance Disorder, ADHD, Autism and Polysubstance Abuse.

The Close Observation Flowsheet dated 10/11/13 documented the patient was in time out from 8:30 AM until 9:00 AM. The flowsheet does not indicate where the patient was located while in time out.

The Close Observation Flowsheet dated 10/11/13 documented the patient was in time out from 4:00 PM until 7:15 PM.

The total amount of time MR # 2 was in time out on 10/11/13 was 3 hours and 45 minutes and repeatedly greater than 30 minutes at a time.

The Close Observation Flowsheet dated 10/12/13 documented the patient was in time out from 10:00 AM until 10:30 AM.

The Close Observation Flowsheet dated 10/12/13 documented the patient was in time out 1:15 PM until 2:30 PM.

The total amount of time MR # 2 was in time out on 10/12/13 was 1 hour and 45 minutes and greater than 30 minutes at a time.

The Close Observation Flowsheet dated 10/14/13 documented the patient was in seclusion room from 2:45 PM through 4:15 PM. There is no order for the patient to be in the seclusion room during this time period and no documentation in the nurses progress notes of him requiring restraint/seclusion or time out.

The Close Observation Flowsheet dated 10/15/13 documented the patient was in time out room from 7:30 PM through 9:45 PM. There is no documentation in the nurses progress notes of him being in time out.

The total amount of time MR # 2 was in time out on 10/15/13 was 2 hours and 15 minutes and greater than 30 minutes.

The Close Observation Flowsheet dated 10/16/13 documented the patient was in time out 8:45 AM until 11:45 AM.

The total amount of time MR # 2 was in time out on 10/16/13 was 3 hours, greater than 30 minutes.

The Close Observation Flowsheet dated 10/17/13 documented the patient was in the seclusion room from 8:45 AM through 2:00 PM. There is no order for this and no restraint/seclusion paperwork completed for this 5 hour and 15 minute stay in the seclusion room. There is no way to know if the patient was in time out or seclusion.

The Close Observation Flowsheet dated 10/18/13 documented the patient was in time out from 1:00 PM through 3:45 PM. There is no order for this and no documentation of where the patient was located during this time out period for this 2 hour and 45 minutes.

The facility failed to follow it's policy on the use of time out.

In an interview 10/24/13 at 8:35 AM with EI # 2, the RN consultant the above information was confirmed. She stated the counselor felt MR # 2 did better being in a quiet environment and the counselors and MHT(Mental Health Technician) worked with the patient while he was in time out.

The surveyor requested the documentation of what was done with the patient and none was provided.

3. MR # 3 was admitted to the facility 9/13/13 with diagnoses of Conduct Disorder, Oppositional Defiant Disorder and ADHD.

On the Multidisciplinary Notes dated 10/7/13 at 6:15 PM the RN documented, " Pt refused to stay with his group or to pull up his pants. He cussed at staff and peers today, pt went to time out twice but said it didn't help him and he wasn't feeling any better..."

There was no documentation in the medical record regarding the time outs.

In an interview on 10/24/13 at 9:49 AM with EI # 8, Counselor # 1, she stated the patient went to time out because he wanted to change groups.

The patient was placed in a therapeutic hold 10/11/13 at 1:53 PM to 2:00 PM and received Vistaril 50 mg (milligrams) IM (intramuscular) at 1:55 PM. The debriefing documented at 2:10 PM," Patient allowed to get up, taken to time out to allow medication to help calm him."

There is no documentation of how long the patient remained in time out.

On 10/13/13 at 9:25 AM the RN documented, " Pt entered the time out room at 9:35."

There was no time documented when he left time out or if his behavior problems continued.

The Close Observation Flowsheet for 10/13/13 documented the patient was in time out from 9:15 until 9:45 with part of the time at the nurses station.

In an interview 10/24/13 at 9:49 AM with EI # 8, Counselor # 1, she confirmed the time was not included in the time out.

4. MR # 5 was admitted to the facility on 10/3/13 with diagnoses of Oppositional Defiant Disorder, Conduct Disorder, ADHD Combined Type and Adjustment Disorder.

A physician's order dated 10/5/13 at 1:50 PM documented, " Pt placed on 1:1 observation after acting out and voicing that she wants to die."

On the Multidisciplinary Notes dated 10/5/13 at 1:00 PM the RN documented, " Pt refused to get out of bed after nap time was over. When staff was finally able to get her out of bed she began to act out, ripping air conditioner cover off of wall and red fire alarm. Pt given PRN (as needed) Vistaril for agitation which was non-effective. Pt continued to fight and shove staff. Stating she wants to die and to get off her. Dr... notified at 1:50 PM who ordered to put her in seclusion and place on 1:1. 1:50, Pt began to head bang and scratch out in seclusion room. Pt placed in manual hold for 20-30 seconds. Pt eventually able to calm down and sat in hall by nurses station."

There was no order in the medical record for use seclusion or manual hold on 10/5/13.

The Close Observation Flowsheet for 10/8/13 documented the patient was in time out 10:15 AM until 10:30 AM, there is no mention of this time out by the RN in her documentation 10/8/13.

In response to the question of why the patient was in time out counselor # 2, EI # 14 referred the surveyor to the Level System behavior Sheet for 10/8/13, " Throwing markers across the room then left group without staff."

The Close Observation Flowsheet for 10/9/13 documented the patient was in time out 6:15 PM until 7:15 PM. There is no mention of this time out by the RN in her documentation 10/9/13.

In response to the question of why the patient was in time out, EI # 14 referred the surveyor to the Level System behavior Sheet for 10/9/13, " Pt got agitated with peer and tried to fight her, profanity."

The Close Observation Flowsheet for 10/11/13 documented the patient was in time out 12:00 until 12:45 PM, there is no mention of this time out by the RN in her documentation 10/11/13.

In response to the question of why the patient was in time out, EI # 14 referred the surveyor to the Level System behavior Sheet for 10/11/13, " Walking out of room without permission, writing bad stuff on table about staff."

The Close Observation Flowsheet for 10/13/13 documented the patient was in time out 3:30 PM until 5:15 PM, there is no mention of this time out by the RN in her documentation 10/13/13.

In response to the question of why the patient was in time out, EI # 14 referred the surveyor to the Level System behavior Sheet for 10/13/13, " Walking out of room, cursing, refused to come outside."

There was no documentation of discussion of the use of time out, the reasons needed or discussion with the treatment team/ physician before being utilized 5 times in 8 days.

In an interview 10/24/13 at 10:13 AM with EI # 14, the Counselor # 2, the above information was confirmed.

Based on review of facility policies and procedures, medical records and interview it was determined the facility failed to document specific orders for restraint and seclusion to include:

1. The time limit

2. Describe specific release behaviors/criteria

3. Describe specific behaviors which resulted in the need for restraint

4. Document the specific procedure/intervention to be used.

This had the potential to affect all patients served by this facility and did affect Medical Record (MR) # 2, # 3, # 6 and # 5.


Policy # A 100.303 Use of Restraint and Seclusion

I. Purpose: To ensure the rights and safety of patients when the use of Restraint or Seclusion are clinically justified.

II. Policy: Beacon's Children's Hospital is committed to promoting an environment that avoids use of restraint, seclusion, coercion by effectively using less invasive and restrictive measures.

V. Procedures:

1. Restraint shall only be implemented pursuant to a written order by a Physician or Certified Registered Nurse Practitioner (CRNP); except in cases of emergency when no Physician or CRNP is present, a Trained Registered Nurse (RN) may implement use of restraint to prevent patient from injuring self/others.

4. Written orders for restraint shall be time limited and meet the following criteria:

a. Designate the specific intervention/procedures authorized, including any specific measures for ensuring the patient's safety, health and well being.

b. Specify the date, time of day, and maximum length of time for which the intervention/ procedure may be used, which will not exceed two (2) consecutive hours for adolescent patients age 10-17 years.

c. Describe the specific behaviors which constituted the emergency which resulted in the need for restraint.

d. Describe the specific release behaviors that the patient must demonstrate before the restraint will be discontinued.

e. Be signed, timed, and dated by the Physician or CRNP or the Trained RN who accepted the prescribing physician's telephone order.

17. Immediately following the release of the patient from restraint, staff will document observations of the patient's behavior during this transition period in the patient's medical record (Progress Notes).

19. When a patient falls asleep in restraint, he or she must be released from restraint immediately unless unsafe to do so.

Medical Record findings:

1. MR # 6 was admitted to the facility 9/4/13 with diagnoses of Bipolar Disorder, Substance Abuse and ADHD (Attention Deficit Hyperactivity Disorder).

The Multidisciplinary Notes documented by the RN on 9/18/13 at 7:45 PM, " Pt (patient ) required manual hold for 30-40 seconds after kicking open locked doors in an attempt to elope. See restraint flowsheet."

There is no order for a manual hold or restraint in the medical record.

The Close Observation Flowsheet dated 9/18/13 documented the patient was at the nurses station at 7:45 PM and then in seclusion room from 8:00 PM until 8:15 PM.

The Restraint/Seclusion Protocol MD (medical doctor) orders protocol dated 9/18/13 at 7:45 PM indicates the physician was notified at 7:50 PM of the manual hold and the patient received Vistaril 25 mg (milligrams) IM (intramuscularly) at 7:50 PM.

There is no signature from the physician on the orders protocol form and no order on the regular physician's order form for the manual hold.

The Restraint/Seclusion Protocol form includes a description of the behaviors at 7:45 PM, " Pt threatening to kick open locked doors while waiting at med (medication) room. Pt went through with threat. Pt placed in manual hold by MHT (Mental Health technician) for 30-40 seconds. At 7:57 PM, pt able to calm down and sat in time out until completely calm."

The Multidisciplinary Notes documented by the RN on 9/19/13 at 7:00 PM, " Pt (patient) became aggressive and combative after escaping through locked unit doors around 6:00 PM. Pt punched wall several times and required manual hold. See restraint flow sheet."

There is no order for a manual hold or restraint in the medical record.

The Close Observation Flowsheet dated 9/19/13 documented the patient was at the nurses station at 6:15 PM and then in time out from 6:30 PM until 7:15 PM. The flowsheet does not indicate where the patient was located while in time out.

The Restraint/Seclusion Protocol MD orders protocol dated 9/19/13 at 6:00 PM indicates the physician was notified at 6:30 PM of the manual hold and the patient received Vistaril 25 mg IM at 6:30 PM.

There is no signature from the physician on the orders protocol form and no order on the regular physician's order form for the manual hold.

The Restraint/Seclusion Protocol form includes a description of the behaviors at 5:58 PM, " Pt kicked through doors near recreation room attempting to escape unit. At 6:00 PM pt unable to get through door near conference room. Pt aggressive and at this point staff intervened and placed pt in manual hold for approximately 90 seconds."

In an interview 10/24/13 at 9:12 AM with Employee Identifier (EI) # 1 , the Director of Nursing, she confirmed there was no order for the use of manual hold.



2. MR # 2 was admitted to the facility 10/9/13 with diagnoses of Conduct Disorder, Oppositional Defiance Disorder, ADHD, Autism and Polysubstance Abuse.

The patient had the following 3 orders for restraint on 10/11/13:

8:20 AM- May restrain pt to prevent harm to self. No longer than 2 hours in restraint.
1:48 PM- Ativan 1 mg IM Stat. Place pt in 4 point restraints due to combative and aggressive behaviors.
2:49 PM- Geodon 20 mg IM for agitation. Initiate 4 point restraint for behaviors.

These orders are incomplete and do not follow the policy for physician orders for restraint.

First order-The Close Observation Flowsheet dated 10/11/13 documented the patient was in time out from 8:30 AM until 9:00 AM. The flowsheet does not indicate where the patient was located while in time out.

The restraint flowsheet indicates the patient was restrained from 8:20 AM until 8:40 AM.

The Restraint/Seclusion Protocol MD orders protocol dated 10/11/13 at 8:20 AM has no documentation the physician was notified of the restraint on the form and the patient received Ativan 1 mg IM at 8:15 AM.

The Restraint/Seclusion Protocol form includes a description of the behaviors at 8:20 AM, "Therapeutic hold perform to keep pt from hurting, 8:35 AM Pt calm down still attempting to take off bandages, 8:40 AM pt discharge from seclusion he has calm down since."

Second order-The Close Observation Flowsheet dated 10/11/13 documented the patient was in seclusion from 1:30 PM until 2:00 PM and then went into time out 2:15 PM until 2:30 PM.

The restraint flowsheet indicates the patient was in 4 point restraints from 1:25 PM until 2:10 PM.

The Restraint/Seclusion Protocol MD orders protocol dated 10/11/13 at 1:25 PM indicates the physician was notified at 1:25 PM of the behaviors and the patient received Ativan 1 mg IM at 1:27 PM.

Third order- The Close Observation Flowsheet dated 10/11/13 documented the patient was in seclusion from 2:45 PM until 3:45 PM and then to time out from 4:00 PM until 7:15 PM.

The restraint flowsheet indicates the patient was in 4 point restraints from 2:45 PM until 3:50 PM.

The physician was notified at 2:45 PM the patient was placed back in restraints and the pt received Geodon 20 mg IM Stat at 2:51 PM.

The Close Observation Flowsheet dated 10/11/13 documented the patient was in seclusion from 7:30 PM until 10:15 PM. There is no order for seclusion for this time period and this is greater than the 2 hours allowed for adolescents.

The total amount of time MR # 2 was in restraint/ seclusion and time out on 10/11/13 was 9 hours.

The patient had the following 2 orders for restraint on 10/12/13:

7:50 AM-Geodon 20 mg IM x 1 only. Four point restraint per protocol.
1:15 PM- Four point restraints per protocol.

These restraint orders are incomplete, the protocol is not signed by the physician.
First order-The Close Observation Flowsheet dated 10/12/13 documented the patient was in seclusion from 7:45 AM until 8:15 AM and then to time out from 10:00 AM until 10:30 AM.

The Restraint/Seclusion Protocol MD orders protocol dated 10/12/13 at 7:50 AM has documentation the physician was notified of the restraint at 7:50 AM and the patient received Vistaril 25 mg IM at 7:55 AM.

The restraint flowsheet indicates the patient was in 4 point restraints from 7:50 AM until 8:05 AM.

The debriefing form documented the events leading up to the restraint, " Pt refused to get out of bed (OOB). Pt was talked by staff and given a chance to get up on his own. Pt refused. MHTs manually removed pt from bed and into seclusion room...Pt placed in restraints by nurse, he was combative."

There is no documentation to indicate who talked with the patient beside the MHT to avoid this incident.

Second order-The Close Observation Flowsheet dated 10/12/13 documented the patient was in seclusion from 1:00 PM and time out 1:15 PM until 2:30 PM.

The Restraint/Seclusion Protocol MD orders protocol dated 10/12/13 at 1:15 PM has documentation the CRNP was notified of combative behavior. The description of the episode documented 10/12/13 at 7:50 AM, pt refused to get OOB this AM. At 10/12/13 1:15 PM, pt refused to get OOB.


The restraint flowsheet indicates the patient was in restraints from 1:15 PM until 3:00 PM. During this time the patient was asleep from 1:45 PM until 2:15 PM and not removed from restraint per policy.

The debriefing form documented the events leading up to the restraint, " Pt refused to get OOB after naptime. MHT talked with pt. Pt was given option to get OOB on his own. Pt refused. MHTs manually removed pt from bed and into group room...Pt was still combative and noncompliant. Moved to seclusion room and put in restraints."

There is no documentation to indicate who talked with the patient beside the MHT to avoid this incident.

The Close Observation Flowsheet dated 10/14/13 documented the patient was in seclusion room from 2:45 PM through 4:15 PM. There is no order for the patient to be in the seclusion room during this time period and no documentation in the nurses progress notes of him requiring restraint or time out.

The Close Observation Flowsheet dated 10/15/13 documented the patient was in time out room from 7:30 PM through 9:45 PM. There is no documentation in the nurses progress notes of him being in time out.

On 10/16/13 at 9:10 AM the physician ordered, "Geodon 20 mg IM now and restrain pt to prevent harm to self and others."

The 10/16/13 order/restraint paperwork was not in the medical record when reviewed by the surveyor. The Close Observation Flowsheet dated 10/16/13 documented the patient was in seclusion from 8:00 AM to 8:15 AM and to time out 8:45 AM until 11:45 AM.

The surveyor received Restraint Flowsheet documentation from EI # 2, the RN Consultant at 8:55 AM on 10/24/13, stating that the original had been lost and the nurse had "redid" the paperwork.

The restraint flowsheet time was documented as 7:15 PM through 8:00 PM the patient was in restraint. This time does not match the time of the order at 9:10 AM.

The Restraint/Seclusion Protocol MD orders protocol dated 10/16/13 at 8:20 PM has documentation the RN initiated the restraints, no documentation the physician was notified. The pt received Geodon 20 mg IM at 7:10 PM.

The Close Observation Flowsheet dated 10/17/13 documented the patient was in the seclusion room from 8:45 AM through 2:00 PM. There is no order for this and no restraint/seclusion paperwork completed for this 5 hour and 15 minute stay in the seclusion room.

The Close Observation Flowsheet dated 10/18/13 documented the patient was in time out from 1:00 PM through 3:45 PM. There is no order for this and no documentation of where the patient was located during this time out period for this 2 hour and 45 minutes.

In an interview 10/24/13 at 8:35 AM with EI # 2, the RN consultant the above information was confirmed. She stated the counselor felt MR # 2 did better being in a quiet environment and the counselors and MHT worked with the patient while he was in time out. The surveyor requested the documentation of what was done with the patient and none was provided.

3. MR # 3 was admitted to the facility 10/2/13 with diagnoses of Oppositional Defiant Disorder, Conduct Disorder, ADHD and Depression.

On 10/13/13 a verbal order was received from the CRNP timed by the RN at 7:50 PM, "Place patient in therapeutic hold/restraint for up to 2 hours to prevent injury to self and others due to pt physically/ verbally aggressive, threatening and combative towards staff and pt not responsive to less restrictive alternatives. May discontinue when pt de-escalates and is no longer exhibiting these behaviors and place on 1:1 observation."

The order does not specify what type of restraint to be used and is written in a way that allows the staff to decide whether to use therapeutic hold or restraint.

The Multidisciplinary Notes dated 10/13/13 at 7:30 PM documented by the RN, " Notified by staff that pt was agitated wouldn't remain in his group. Pt became physically verbally, aggressive, threatening, yelling and combative toward staff. Pt was then removed from hallway per staff using CPI (Crisis Prevention Institute training) and placed in 4 point restraints due to pt's not responsive to less restrictive alternatives. At 7:50 PM CRNP notified new orders received for therapeutic hold/restraint.

At 8:40 PM, "Pt out of restraint at this time."

The restraint flowsheet for 10/13/13 indicates the patient was in restraints from 7:40 PM until 8:40 PM.

The Restraint/Seclusion Protocol MD orders protocol dated 10/13/13 at 7:40 PM has documentation the RN initiated the restraints and the CRNP was notified at 7:50 PM. The pt received Vistaril 25 mg IM at 7:42 PM.

The policy for restraints and seclusion was not followed.

In an interview 10/24/13 at 10:30 am with EI # 1, Director of Nursing the above information was confirmed.

4. MR # 5 was admitted to the facility on 10/3/13 with diagnoses of Oppositional Defiant Disorder, Conduct Disorder, ADHD Combined Type and Adjustment Disorder.

A physician's order dated 10/5/13 at 1:50 PM documented, " Pt placed on 1:1 observation after acting out and voicing that she wants to die."

On the Multidisciplinary Notes dated 10/5/13 at 1:00 PM the Registered Nurse (RN) documented, " Pt refused to get out of bed after nap time was over. When staff was finally able to get her out of bed she began to act out, ripping air conditioner cover off of wall and red fire alarm. Pt given PRN ( as needed) Vistaril for agitation which was non-effective. Pt continued to fight and shove staff. Stating she wants to die and to get off her. Dr... notifed at 1:50 PM who ordered to put her in seclusion and place on 1:1. 1:50 Pt began to head bang and scratch out in seclusion room. Pt placed in manual hold for 20-30 seconds. Pt eventually able to calm down and sat in hall by nurses station."

There was no order in the medical record for use seclusion or manual hold on 10/5/13.

The Restraint/Seclusion Protocol MD (medical doctor) orders protocol dated 10/5/13 at 1:50 PM has documentation the RN initiated the restraints, and the physician was notified at 1:49 PM. The pt received Vistaril 25 mg IM at 1:40 PM.

The Restraint/Seclusion Protocol form includes a description of the behaviors at 1:38 PM, " Pt agitated and combative, hitting fire alarm and box off wall, hitting staff. 1:40 PM, PRN agitation medication given, uneffective. Pt continues to be combative and damaging property, hitting and grabbing staff. 1:50 PM, Pt put in therapeutic hold for 10 seconds to be put in seclusion room. Door closed, pt begins head banging almost instantly and trying to scratch self, door reopened within 60 seconds."

There was no order in the medical record for use seclusion or manual hold on 10/5/13.

In an interview 10/24/13 at 10:30 AM with EI # 1, Director of Nursing the information was confirmed.

Based on observation, document review and review of policy and procedure and interviews, the facility failed to provide adequate numbers of Registered Nurses (RNs) to provide nursing care, supervise and monitor patients. The facility's staffing pattern results in limited time for the RN to provide active treatment and limited opportunity to provide direction and supervision of non-professional nursing personnel in the provision of nursing care. The facility's staffing patterns failed to provide adequate numbers of Mental Health Technicians to provide care to the patients to support the treatment plans and meet the patients needs. This had the potential to affect all patients served by this facility.

Findings include:

Policy # 900.200 Staffing, Scheduling of Nursing Service Personnel

I. Purpose
The purpose of this policy is to provide guidelines on scheduling nursing service personnel to meet patient care requirements.

II. Scope
This policy applies to all full time and part time non-exempt direct care giver nursing service personnel (RN's, LPN's, and MH Techs)[ Licensed Practical Nurses and Mental Health technicians].

III. Background/Rationale
Staffing remains a challenge for nurse managers and administrators. It is a never ending balancing act between providing adequate staffing for quality patient care and meeting the bottom line. Schedules frequently have to be changed on short notice because of changes in patient care requirements, illness of a nurse, etc.

C. Flexible Scheduling
DON (Director of Nursing) will evaluate staffing needs based on established grids and criteria and will plan coverage to meet patient/unit need.

Policy # 900.300 Nursing Staffing Plan

I. Purpose:

The Staffing Plan is based on Patient census and acuity. The system reflects the categories of available nursing personnel, infection control standards, safety considerations, unit acuity, method of patient delivery and additional staffing as needed.

II. Policy:

A. Nursing unit will be staffed with RN's, LPN's and MHT's as needed to meet patient needs and allow staff participation in educational and unit meetings.

B. The staffing is reviewed and changes are made as patient volume and acuity dictates at a management level.

Beacon Children's Hospital staffing Matrix revised 4/18/13
Patients= 17-24 for the day shift and night shift 1 RN assigned, 1 LPN assigned and 5 MHTs assigned.

Policy: A100.609
Manual: Administration
Title: High Alert Medication Management
Review Date: 7/23/12

Policy: " Beacon Children's Hospital shall maintain a list of high alert medications (meds) that require specific safeguards to reduce the risk of errors...
High alert meds are drugs that have an increased risk of causing significant harm...special precautions will be employed with their overall management..."

Procedure:

"1. The following are specific medications that require special precautions...
Specific High Alert Drugs:
Insulin
Ativan Injectable
Haldol Deconate
Risperdal Consta

2. Two licensed nurses will verify the dosage and correct medication on each dose of the Specific High Alert Medications listed above."


***

Findings include:

While the surveyors were onsite the census was as follows:

Midnight Census 10/21/13 = 20 patients
Midnight Census 10/22/13 = 21 patients
Midnight Census 10/23/13 = 21 patients
Midnight Census 10/24/13 = 22 patients

A. Observations

Observations occurred 10/23/13 at 10:15 AM by the surveyor:

A new patient arrived to the door where the surveyor was working, accompanied by her mother and the RN from the floor, Employee Identifier (EI) # 12 who directed them to a room across the hall to complete the admission paperwork and assessment.

At approximately 10:45 AM the surveyor observed the LPN from the floor, EI # 13, in the front lobby with a patient being discharged waiting on his family.

There was no nurse on the floor with the patients at this time as the RN was doing the admission and the LPN was in the lobby. EI # 1, the Director of Nursing (DON) was in EI # 3, the Administrator's, office.

The surveyor spoke with EI # 12, the RN at 12:15 PM in the hallway outside the main doors to the unit and she was expecting a second admission to arrive.

An interview was conducted at 12:40 PM on 10/23/13, with EI # 12 regarding the staffing with new patients being admitted. EI # 12 confirmed the floor was left without a nurse earlier while she was doing an admission and the LPN, EI # 13 was off the floor with a discharge.

EI # 12 stated that all new admissions were to be 1:1 for the first 24 hours and now they had two new admissions and the same 5 MHTs they had started with at 7:00 AM. This would remove 2 MHTs from the groups to be occupied with the 1:1 female patients and leave 3 MHTs to work with the groups.

An interview was conducted with EI # 1, the DON on 10/23/13 at 1:55 PM. EI # 1 verified all of the staff work 12 hour shifts and that the typical pattern is 1 RN, 1 LPN and 5 MHTs for both shifts for the number of patients they currently have.

EI # 1 confirmed if a patient is on 1:1 the MHT is dedicated to that patient only. If a MHT is with a patient in restraint another worker is expected to take over the other duties of the MHT.

EI # 1 confirmed that there should not be a time when both nurses are off the floor.

The surveyor asked EI # 1 if she felt staffing was adequate for the facility. EI # 1 stated that they were still doing orientation and trying to hire a pool to keep help available.

The surveyor observed on 10/23/13 at 2:40 PM, patients in the recreation room, two of the new patients who were on 1:1, patients in the dining room and patients outside. The LPN was going back and forth escorting patients to the back hall for telemedicine with the Psychiatrist and staying with the patients to receive orders as needed from the doctor.

The patients returned from outside with the RN and a MHT at 2:50 PM. The floor was again uncovered while both nurses were occupied with patients away from the patient care area.


Medical Record (MR) Findings:


1. MR # 4 was admitted to the facility 10/2/13 with diagnoses including Oppositional Defiant Disorder, Conduct Disorder, Attention Deficit Hyperactivity Disorder (ADHD) and Depression.

On 10/24/13 at 8:49 AM during review of medication records in the med room, the surveyor observed MR # 4 exhibit aggressive behavior.

Phone orders were received for the use of 4 point restraints and Ativan 1 mg (milligram) IM (intramuscularly) stat (now). Verbal report regarding Ativan 1 mg IM stat order was communicated between EI # 11, RN, charge nurse and EI # 10, LPN, med nurse. EI # 10 prepared the high alert drug Ativan in the med room while EI # 11 assisted with MR # 4's restraint application in the time out room.

There was no verification of the specific high alert medication Ativan injectable by two licensed nurses as per facility policy.

Further review of MR # 4's MAR (Medication Administration Record) revealed Ativan 1 mg IM stat was administered 10/23/13 at 8:35 PM. The documentation revealed one nurse initialed for the 10/23/13 8:35 PM MAR entry.

MAR documentation failed to include two nurses initials for dosage and correct medication verification of the high alert medication Ativan as per policy.

A 10/24/13 12:10 PM interview with EI # 1, RN, Director of Nurses, who was present during the time MR # 4 was being restrained, validated staff failed to follow the high alert medication management policy during the Ativan preparation.

2. MR # 6 was admitted to the facility 9/4/13 with diagnoses of Bipolar Disorder, Substance Abuse and ADHD.

On 9/14/13 at 9:15 PM, the Interdisciplinary Notes, the RN documented, " Pt insisted to go into the seclusion room and when told there was not staff at this time to sit with him he continued to make threatening statements and refused to walk away from one of the locked doors that he recently kicked in. Another staff member was able to speak with pt and have him move to a chair closer to recreation room where staff could monitor closely."

The Close Observation Flowsheet dated 9/14/13 documented the patient was in time out from 7:30 PM until 9:15 PM at the nurses station.

A review of the daily staffing for 9/14/13 documented one RN, one LPN and 5 MHTs on 7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM.

The facility failed to provide adequate staff to meet the treatment needs of the patients.

These observations revealed that the RN assigned had duties that included admitting patients, discharging patients, assisting the medication nurse with administering PRN (as needed) medications and verifying high risk medications, meeting with the attending physician during patient rounds or assisting with telemedicine by escorting patients to the room and taking orders from the Psychiatrist during telemedicine, transcribing physician's orders, and answering phones. The RN would leave the floor when doing an admission process and assessment leaving the LPN (Licensed Practical Nurse) to provide medications and oversight of the care the patients were receiving in group therapy and classroom activities. The RN was able to provide limited supervision in providing patient care by the MHT and had very few opportunities to provide active treatment.


In an interview 10/24/13 at 10:00 AM, EI # 1, the DON confirmed the above findings.

This condition of participation for Pharmaceutical Services is out of compliance based on observation, review of policy and procedures and review of Medication Administration records.

The facility failed to:

1. Provide ordered medications to patients timely.

2. Evaluate therapeutic response and results of PRN (as needed) medications

3. Destroy unusable drugs in the facility.

4. Ensure medications available for patient were not expired and were stored according to facility policy.

This had the potential to affect all patient served by the facility.


Refer to A 493, A 500 and A505.

Based on policy and procedure, medication administration reviews and interview, it was determined the facility failed to administer ordered medications. The facility failed to document the reasons medications were not administered. This had the potential to negatively affect all patients served by the facility and did affect unsampled medical records (MR's) # 7, # 8, # 9, # 10, # 11 and sampled record, MR # 4.

Findings include:

Policy: A100.603
Manual: Administration
Title: Medication Administration Record (MAR)
Revision Date: 12/2011

Policy "...provide a complete and permanent record...and documentation of all medications through the use of a Medication Administration Record...
Procedure:
...5. If a medication is not given (patient refuses), the nurse will circle the medication dosage and initial, noting the reason the dose was not given on the back of the MAR...
7. The nurse administering medications should sign and initial the back of the MAR..."


Following the 10/21/13 8:00 AM (morning) medication (med) pass with Employee Identifier (EI ) # 4, Licensed Practical Nurse, the surveyor reviewed the facility's medication record administration documents. Medical records and medication records revealed the following patient's had not received medications as ordered by the physician:

1. MR # 7 was admitted to the facility 9/17/13 with diagnoses including Command Auditory Hallucinations and Assaultive Behavior. Geodon 40 mg (milligram) BID (twice daily) with meals was prescribed on 9/17/13 at 12:30 PM (evening).

Review of MR # 7's medication record administration failed to reveal the 10/16/13, 5:00 PM Geodon was administered. The nurse's medication notes did not contain documentation the reason Geodon was not administered as ordered.

2. MR # 8 was admitted to the facility 10/3/13 with diagnoses including Hearing Voices and SAOB (sexually acting out behavior). Record review revealed Paxil 20 mg po (by mouth) at bedtime (hs) was prescribed 10/11/13 at 9:50 AM.

Review of MR # 8's medication administration record failed to reveal the 10/16/13 9:00 PM dose of Paxil was administered. The nurse's medication notes failed to include documentation the reason the 10/16/13 Paxil dose was not administered as ordered.

3. MR # 9 was admitted to the facility 10/4/13 with diagnoses including Suicidal Ideation and Stealing. Record review revealed the physician ordered an increase in the dosage of Abilify 5 mg at hs to Abilify 15 mg at hs on 10/10/13 at 6:40 PM.

Review of MR # 9's MAR revealed the patient received Abilify 5 mg 10/10/13 at 9:00 PM. The nurse medication notes failed to include documentation the reason Abilify 15 mg was not administered as ordered.

4. MR # 10 was admitted to the facility 10/14/13 with diagnoses including Oppositional Defiant Disorder, Conduct Disorder and Attention Deficit Hyperactivity Discorder. Record review revealed 10/14/13, 11:00 AM medication orders included Xopenex 1.25 mg nebulizer q (every) 4 hr prn (as needed) at least BID (twice daily), Lortadine 10 mg po daily and Melatonin 5 mg 2 (tablets) po q (every) hs.

Review of MR # 10's MAR failed to contain documentation Xopenex 1.25 mg nebulizer was administered 10/14/13 at 9:00 PM or 10/15/13 at 9:00 AM. Lortadine 10 mg po daily was not administered 10/15/13 at 9:00 AM. Melatonin 5 mg 2 po at hs was not administered 10/14/13 at 9:00 PM. The nurse medication notes failed to include documentation the reason Xopenex BID, daily Lortadine and bedtime dose of Melatonin was not administered as ordered 10/14/13 and 10/15/13.

During a 10/21/13 10:15 AM interview, Employee Identifier (EI) # 4, Licensed Practical Nurse (LPN), medication (med) nurse, reviewed the above patient's medication records. EI # 4 verified the MAR documentation revealed the patients did not receive ordered medication. EI # 4 confirmed the MAR's did not include documentation of reasons the patients failed to receive ordered medications.

5. MR # 11 was admitted to the facility 10/23/13 with diagnoses including Suicidal Ideation, Defiant and Aggression. Orders for Saphris 5 mg po q hs were received on 10/23/13 at 1:40 PM.

Review of MR # 11's MAR failed to reveal Saphris 5 mg was administered 10/23/13 at 9:00 PM as ordered. There was no documentation on the medication record as to the reason the Saphris was not administered.

An interview was conducted with EI # 10, LPN, med nurse and EI # 11, Registered Nurse, charge nurse, on 10/24/13 at 8:45 AM. The facility staff verified Pt. E had not received Saphris 10/23/13 as ordered.

6. Review of MR # 4's MAR included 10/8/13 orders for Bentyl 10 mg po bid (twice daily). MAR documentation 10/22/13 at 8:00 PM revealed Bentyl was not administered with "unable to give no med" as the reason. 10/23/13 and 10/24/13 9:00AM doses were initialed and circled by the nurse. There was no reason documented why the Bentyl was not administered. The 10/23/13 8:00 PM Bentyl dose documentation was a circle with a line drawn through as to reflect the Bentyl was not administered. There was no documentation why the nurse failed to initial and circle the 10/23/13 8:00 PM Bentyl dose. There was no documentation as to the reason the Bentyl was not administered as ordered.

Staff failed to administer Bentyl as ordered for a total of 3 doses on 10/22/13 and 10/23/13. There was no documentation to explain why medications were not administered as ordered and MAR documentation completed per facility policy and procedure.

Based on policies and procedures, observation, Medication Administration Records (MAR's) and interview, it was determined the facility failed to ensure:

1. Staff followed facility policy for High Alert Medication management during Ativan administration

2. Staff evaluated therapeutic response and results of PRN (as needed) medications.

This had the potential to negatively affect all patients served by the facility and did affect medical records (MR's) # 4 and # 6 and unsampled MR's # 9 and # 10.


Findings include:

Policy: A100.609
Manual: Administration
Title: High Alert Medication Management
Review Date: 7/23/12

Policy: " Beacon Children's Hospital shall maintain a list of high alert medications (meds) that require specific safeguards to reduce the risk of errors...
High alert meds are drugs that have an increased risk of causing significant harm...special precautions will be employed with their overall management..."

Procedure:

1. The following are specific medications that require special precautions...
Specific High Alert Drugs:
Insulin
Ativan Injectable
Haldol Deconate
Risperdal Consta

2. Two licensed nurses will verify the dosage and correct medication on each dose of the Specific High Alert Medications listed above.


Policy: A100.603
Manual: Administration
Title: Medication Administration Record (MAR)
Revision Date: 12/2011

Policy "...provide a complete and permanent record...and documentation of all medications through the use of a Medication Administration Record...
Procedure:
...5. If a medication is not given (patient refuses), the nurse will circle the medication dosage and initial, noting the reason the dose was not given on the back of the MAR."
6. Initials used in documenting must be identified by the nurses's signature.
7. The nurse administering medications should sign and initial the back of the MAR.
8. Medications requiring verification by another nurse (Example:Insulin) are to be verified by another nurse prior to administration.
9. The verifying nurse must co-sign the MAR.


Policy Number A100.600
Title: Medication Administration
Revision Date: 7/24/12

Purpose:
1. To provide accurate and timely documentation of the patient's medications...treatments involving medications, as well as scheduled and PRN (as needed) medications.
2. To ensure safe medication administration for all patients...

General Information
2. " Security of medications at Beacon Children's Hospital is maintained in medication carts, locked stock medication cabinet, and in the locked refrigerator located in the medication room which remains locked at all times...
Transcription Guidelines and MAR Information
...PRN (as needed) orders-...
C. Notify the MD (medical doctor)/NP (Nurse Practitioner) if PRN orders do not provide the symptomatic relief intended...
Administration of Medications
...12. Refer to High Alert Medication policy when administering high alert medications..."

Documentation
1. The nurse will sign initials and full signature on the back of the MAR in the designated space at the beginning of the shift.
2. The nurse will sign initials in the designated block that corresponds to the time the nurse administered medications during the assigned shift...
"...5. All responses to PRN medications administered (including pain medications) should be documented on the back of the MAR... Pain medications should have the patient's pain level (0-10) (pain scale with 0 being no pain and 10 being the worst pain) recorded at the time the dose is given. Patient's response should also be recorded using the pain scale..."


1. MR # 4 was admitted to the facility 10/2/13 with diagnoses including Oppositional Defiant Disorder, Conduct Disorder, Attention Deficit Hyperactivity Disorder and Depression.

On 10/24/13 at 8:49 AM during review of med records in the med room, the surveyor observed MR # 4 exhibit aggressive behavior. Phone orders were received for the use of 4 point restraints and Ativan 1 mg (milligram) IM (intramuscularly) stat (now). Verbal report regarding Ativan 1 mg IM stat order was communicated between Employee Identifier (EI) # 11, Registered Nurse (RN), charge nurse and EI # 10, Licensed Practical (LPN), med nurse. EI # 10 prepared the high alert drug Ativan in the med room while EI # 11 assisted with MR # 4's restraint application in the time out room.

There was no verification of the high alert medication Ativan injectable for correct medication and dosage by two licensed nurses as per facility policy.


Further review of MR # 4's MAR revealed Ativan 1 mg IM Stat was administered 10/23/13 at 8:35 PM. The documentation revealed one nurse initialed for the 10/23/13, 8:35 PM, MAR entry. MAR documentation did not include two nurses initials for dosage and correct medication verification of the high alert medication Ativan as per policy.


A 10/24/13, 12:10 PM, interview with EI # 1, RN, Director of Nurses, who was present during the time MR # 4's was being restrained, validated staff failed to follow the high alert medication management policy for Ativan preparation.

Review of MR # 4's 10/1/13 to 10/23/13 MAR failed to include documentation of PRN med effectiveness of 10/3/13 orders for Vistaril 25 mg po (by mouth)/IM q (every) 8 hrs (hours) PRN and Bentyl 10 mg po daily PRN. The MAR documentation revealed 15 of 19 times Bentyl and Vistaril were administered between 10/3/13 and10/23/13. The documentation failed to include the patient's response to prn medications.

2. MR # 6 was admitted to the facility 9/5/13 with diagnoses including Bipolar Disorder, Substance Abuse and Attention Deficit Hyperactivity Disorder.

Review of the 9/5/13 admission orders and the MAR included Vistaril 25 mg po/IM q (every) 8 hrs prn anxiety/insomnia and Tylenol 325 mg 1 to 2 tabs po 4 hrs prn. 3 of 15 times Vistaril and Tylenol were administered between 9/6/13 and 9/13/13 staff failed to document response/ results to the PRN meds.

Further MAR review included documentation on 9/6/13 at 8:10 PM Tylenol was administered for tooth pain and 9/19/13 at 9:05 AM Motrin for headache. There was no MAR documentation of the patients pain scale before or after medication administration per facility policy.

3. MR # 9 was admitted to the facility 10/4/13 with diagnoses including Suicidal Ideation and Stealing.

Review of the 10/8/13 MAR revealed orders for Vistaril 25 mg cap (capsule) po q 8 hrs prn insomnia/anxiety, Hydroxyzine HCL (hydrochloride) 50 mg/ml (milliliter) inj (injectable) 0.5 cc (cubic centimeter) IM q 6 hrs prn insomnia/anxiety and Ibuprofen 600 mg 1 tablet po q 6 hrs after meals prn pain.

Review of the MAR revealed Vistaril po or IM was administered 5 times between 10/14/13 and 10/19/13. There was no documentation of the patient's response or results of Vistaril. Motrin was administered 5 times between 10/14/13 and 10/21/13. MAR documentation failed to include the patients pain scale rating before and after medication administration or response/results from Motrin.

4. MR # 10 was admitted to the facility 10/14/13 with diagnoses including Oppositional Defiant Disorder, Conduct Disorder and Attention Deficit Hyperactivity Discorder.

Review of MR # 10's MAR included 10/14/13 orders for Motrin 600 mg po q 6 hrs prn pain and Tylenol 500 mg q 4 prn. Documentation revealed Motrin was administered 10/17/13. There was no pain scale rating documented before or after Motrin administration. The MAR documentation failed to include response/results of the Motrin.

Review of the MAR revealed Tylenol was administered 10/19/13 and 10/21/13. The 10/19/13 MAR documentation failed to include pain scale rating before and after Tylenol administration. The 10/21/13 Tylenol administration documentation consisted of only nurse initials. There was no nurse's medication note entry for the 10/21/13 Tylenol dosage, reason administered, results/response or pain scale rating.

Based on observations, policies and procedures and staff interview, it was determined the facility failed to ensure that all medications (meds) available for patient use in the facility were not expired and stored according to facility policy. This had the potential to affect all patients served by the facility and did affect unsampled medical records (MR's) # 7, # 12, # 13, # 14, # 15, # 16, # 17, # 18, # 19, # 20, # 21 and # 22.

Findings include:

Policy Number A100.600
Title: Medication Administration
Revision Date: 7/24/12
Purpose:
...To ensure safe medication administration for all patients...
General Information
2. Security of medications at Beacon Children's Hospital is maintained in medication carts, locked stock medication cabinet, and in the locked refrigerator located in the medication room which remains locked at all times...

Expiration Dates
...2. When multi-dose vials are utilized...an expiration date of 28 days from initial vial entry should be used...
3. " The nurse will remove any expired medication and place it in the pharmacy return bin..."

Documentation
...5. "All responses to PRN (as needed) medications administered...should be documented on the back of the MAR (Medication Administration Record) and in the nurses notes..."

"...Discharged Patients
1...Any medication, such as prn's (as needed), that will not be continued at home will be placed in the pharmacy basket for return to the pharmacy...
2. the remaining medication will be sent with the patient/guardian as packaged..."

Policy Number: A100.615
Manual: Administration
Title: Patients Personal Medications
Revision Date: 7/2012

...Procedure:

B "...The patient's home medications will be stored in the medication room..."
C "...Any personal medications not given to family at discharge will be mailed to the patient/guardian or destroyed within thirty days by staff/ pharmacy."


1. A tour of the facility including the medication (med) dispensing room was conducted 10/21/13 at 2:03 PM. During this tour, one 10 milliliter (ml) vial of open, not dated, Tuberculin Purified Protein (PPD) (lot number 3003027) was observed in the locked med room refrigerator.

In the med cabinet, one 7 ounce (oz) bottle of 250 cc (cubic centimeters) Sodium Chloride 0.9 % (percent) irrigant, containing 210 cc was open and not dated. One 16 oz open bottle of Hydrogen Peroxide, dated 5/2/13 was found in the medication cabinet. One bottle of Povidine-Iodine 10 % solution, dated 7/23/13 for MR # 20 was found in the med cabinet. Employee Identifier (EI) # 4, Licensed Practical Nurse, (LPN), med nurse reported MR # 20 was not a current patient.

There was no date or label on the Tuberculin PPD or Sodium Chloride as to when the meds were opened or when they would expire. The Hydrogen Peroxide open date was greater than 28 days per facility policy. The Povidine-Iodine solution had not been placed in the return to pharmacy basket following patient discharge per facility policy.

A plastic bin labeled "Return to Pharmacy" was sitting on the counter in the med room. The following patient meds were observed in the unlocked plastic bin:
MR # 20-Hydroxyzine 25 mg (milligram) po (by mouth) q (every) 8 hr (hour) prn (as needed), Ibuprofen 600 mg 1 po q 6 hr prn, SMZ-TMP (sulfamethoxazole-trimethoprim) DS 1 po bid (twice daily) x (for) 10 d (days) and Remeron 45 mg 1 tab (tablet) po q hs (bedtime).
MR # 21-Vistaril 25 mg 1 po q 8 hr prn.
MR # 22-Hydroxyzine 50 mg cap (capsule) 1 q 8 hr prn and Ibuprofen 600 mg 1 po q 6 hr prn.

Further observation and interview 10/23/13 at 2:30 PM with EI # 4 revealed the facility did not document controlled and non-controlled medications pending return to the contract pharmacy. There were no logs of medications returned to the pharmacy available to the surveyors.

EI # 4 reported to the surveyor patient's personal meds discontinued or changed and facility medications no longer prescribed are placed in the "Return to Pharmacy" plastic bin and the pharmacy picks meds up from the facility quarterly.

The facility failed to maintain all meds in locked medication carts, locked stock medication cabinets, or in the locked refrigerator as per policy. There were expired meds and meds open not dated available for use found in the med room. The "Return to Pharmacy" plastic bin was not secured or locked as per facility policy.

An interview conducted on 10/21/13 at 2:55 PM with EI # 4, confirmed the aforementioned findings.

On 10/22/13 at 11:20 AM the surveyor observed the plastic bin labeled "Return to Pharmacy" to contain additional meds than on 10/21/13. Review of the contents in the unlocked plastic bin labeled " Return to Pharmacy" sitting on the counter in the med room contained the following patient home medications:
MR # 12-Fluoxetine 20 mg 1 cap q d, # 18, fill date 8/10/13, Clonidine HCL (hydrochloride) 0.1 mg 1 tab (tablet) at hs # 48, fill date 5/8/13 and
Amoxicillin 500 mg 1 tid, # 15, fill date 9/26/13.
MR # 13-Cetrizine 10 mg 1 tab q pm (evening) for allergy, # 10, fill date 7/30/13.
MR # 14 Acyclovir 400 mg 1 tab three times daily x 7 d, # 1, fill date 9/17/13.
MR # 15-Lamotrigine 25 mg tab 4 po q d, # 2, fill date 9/16/13.
MR # 7-Cephalexin 500 mg 1 cap po x 10 d, # 17, fill date 9/16/13.
MR # 16-Rispridone 0.5 mg 1/2 (one half) tab twice daily, several pieces of a dark red pill, fill date 8/24/13.
MR # 17-Clonazepam 0.5 mg 1 tab po bid, # 1, fill date 9/19/13.
MR # 18-ProAir HFA (hydrofluroalkine) 90 mcg (micrograms) inhale 2 puffs q 4-6 hrs prn wheezing, 1 inhaler,fill date 8/22/13.
MR # 19-Nuva Ring 0.120 mg/0.15 mg per day. This medication did not have a prescription label or date on it. A patient's name was hand written on medication package.

The above patient home meds had prescription fill dates greater than 30 days and had not been returned or destroyed as per facility policy.

Based on policies and procedures, observations and interviews, it was determined the hospital failed to ensure food was prepared and stored in a safe and sanitary manner and sanitary measures were used in garbage disposal. This had the potential to negatively affect all patients served by the facility.

Findings include:


Policy: OP3 0212.04
Manual: Dietary
Title: Seasoning Foods

...Procedure:
9. Purchase seasonings in small quantities
10. Store in tightly sealed containers in a cool, dry location away form direct light.
(If properly stored, ground and whole spices have a 3-4 year shelf life.)


Policy: FP.10.
Manual: Dietary
Title: Food Storage Labeling
Policy:
The facility will ensure the safety and quality of food by following good storage and labeling procedures.
Procedure:
1. Labeling:
a. All temperature controlled foods and ready to eat foods that are prepared in the facility and held for longer than 24 hours will be labeled. Information included on the label:
i. Name of Food
ii. Date and time of storage
iii. Date by which it should be eaten or discarded. (USE BY DATE)
...5. Product Placement:
a. Food is stored in container that are durable, leak proof and can be tightly sealed or covered.


Policy: OP3 0210.01
Manual: Dietary
Title: Storing Dry Foods
...2. " Store damaged canned goods in a separate and distinct area of the storeroom away from other food items..."


Policy: FP.4.
Manual: Dietary
Title: Calibration of Thermometers
Policy: Facility shall ensure that a thermometer gives accurate recordings.
Procedure:
1. All thermometers are to be calibrated:
Procedure:
...2. Ice Point Method:
a. " Fill a large container with crushed ice and add clean tap water...
b. Put the thermometer stem or probe into the ice water so the sensing area is completely submerged...
C. Wait 30 seconds or until the indicator stops moving.
d. Hold the calibration nut securely with a wrench ...and rotate the head of the thermometer until it read 32 degrees F..."


Policy: FP.3.
Manual: Dietary
Title: Guidelines for Using Thermometers
Policy: The facility shall monitor temperatures of hazardous foods to maintain quality and safety of food served.
Procedure:
...2. Thermometers are calibrated to ensure accuracy.
...5. " Wait at least 15 seconds after the indicator stops moving..."


Policy: FP.8.
Manual: Dietary
Title: Monitoring Temperatures of Cooked Foods

Policy:
The temperature of potentially hazardous cooked foods will be monitored to insure that foods are not in the danger zone (above 41 degrees F (Fahrenheit) and below 135 degrees F) for more than 6 hours.

Procedure:
2 "...Foods must be cooked to the proper internal temperature for 15 seconds...
I. Pork...155 degrees F"

During the initial tour of the kitchen 10/21/13 at 10:25 AM, Employee Identifier (EI) # 5, dietary employee, was observed checking food temperatures. The surveyor observed EI # 5 monitor temperatures for pork chops, cheesy noodles, apple sauce, turnips, milk and fruit punch. EI # 5 failed to follow facility policy for thermometer calibration using the Ice Point Method. EI # 5 attempted to calibrate the thermometer with the wrench after removing the thermometer from the cup of ice numerous times. EI # 5 did not wait 15 seconds following thermometer calibration prior to monitoring food temperatures. During the temperature monitoring, EI # 5 required prompting by EI # 7, dietary manager on the correct technique to calibrate food thermometers using the Ice Point Method.

Observations on 10/21/12 at 10:45 AM in the food service area revealed the following:

Main Kitchen Area underneath stainless steel counter: Items stored in a plastic box without closed lids: Seasoning build up on the bottle tops observed and bottle tops were open on the following:
One 35 oz bottle of meat tenderizer
One 20 oz bottle of onion powder
One 16 oz bottle of garlic powder
One 33 oz bottle of seasoned salt

Main Kitchen Area underneath stainless steel counter: observed items stored and not dated:
One large plastic bottle of seasoned salt
One 18 oz ground cinnamon
One 11 oz parsley flakes- date not legible
One 12 oz Poultry seasoning
One 16 oz whole celery seed- no year documented

The surveyor observed the stainless steel storage counter bottom shelf covered with a net shelf liner. Food crumbs and the appearance of rust build up was observed. EI # 6, dietary employee reported it had been approximately 3 weeks since she had cleaned the area.

The surveyor observed a dented can on the use shelf: Diced Peaches (large) 105 oz. The date (day) documented on the can was not legible. The dented can was not in the designated area. EI # 7, dietary manager removed the dented can and placed it in the "do not use" shelf area.

In an interview 10/21/13 at 1:05 PM, EI # 7 verified correct use and thermometer calibration was not performed during observation per facility policy.


Observations on 10/21/13 at 1:10 PM in the food service area revealed the following:

Juice Cooler:
2 pounds liquid whole eggs with citric acid- not dated

Dry Storage area:
One 10/17/13 open 12 oz biscuit gravy mix in a zip lock bag, bag not closed
One bag chicken/brown gravy mix open/dated 9/15/12, not in a closed bag
One 5 pound bag Quaker grits, opened 10/15/13, not in a closed bag
One 24 oz bag Texas Toast, open/not dated or labeled

Observations on 10/23/12 at 9:15 AM in the food service area revealed the following:

Walk in Cooler: 1 pack of 12 Colonial Party Buns and 1 pack of rolls not dated or labeled.

EI # 7 discarded the above items during the tours.

An interview conducted 10/21/13 at 10:40 AM with EI # 7 confirmed items were not properly stored, dated and labeled and that the counter bottom was not clean.

On 10/23/13 at 12:34 PM with dietary employee, EI # 6, the surveyor viewed the outside dumpster. The dumpster was observed to have an area of rust on the left lower side measuring half the length of the container. The surveyor was able to visualize paper through the open area. EI # 6 validated the dumpster needed to be replaced as garbage would be able to escape from the rusted area.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged, and maintained to ensure patient safety.

Findings include:

Refer to the Life Safety Code violations.

Based on review of facility policy and procedure, review of medical records and interview it was determined in 2 of 2 discharge records reviewed the facility failed to implement the discharge plan and notify the receiving facility of the patient's needs including medications and wound care.

This had the potential to affect all patients served by this facility and did affect Medical Record (MR) # 3 and # 6.

Findings include:

Policy # A100.505 Discharge Planning and Summary

Policy: It shall be the policy of Beacon Children's Hospital to provide effective and timely discharge planning, beginning with admission and involving the patient, family/guardian and available community resources.

Procedure:

C. Documentation of ongoing discharge planning shall be incorporated into the patient's Individualized Treatment Plan.

D. The Discharge Plan Summary shall be completed prior to the patient's discharge.

E. Each patient shall have a written Discharge Plan Summary in which the patient, and when appropriate, the family and/or significant others have participated.

G. The Discharge Plan Summary shall reflect that there has been adequate preparation of the patient and that appropriate arrangements for discharge have been made.

H. The discharge plan shall contain, at a minimum, information regarding:

2. Medication information
3. Aftercare instructions
4. Medical management information/appointments
5. Discharge referrals/appointments
6. Condition of discharge
9. Disposition/living arrangements

J. Each patient, the family and or significant other (as appropriate) and the primary caregiver shall receive a copy of the Discharge Plan Summary upon the patient's discharge.

II. Procedure

A. Nursing will initiate the Discharge Instruction Sheet at the time of the patient's order for discharge.

C. Complete the medication section:
1. List the names of the patient's discharge medications.
2. List the dosage of each medication.
3. List the time, in hours, that the patient is to take the medication.
5. Nursing should list any recommended medical follow-up that is needed.

Medical record findings:

1. MR # 3 was admitted to the facility 9/13/13 with diagnoses of Conduct Disorder, Oppositional Defiant Disorder and ADHD (Attention Deficit Hyperactivity Disorder).

A physician's order was present in the medical record 10/18/13 at 12:45 PM to discharge to Teen University on 10/18/13.

When the record was reviewed by the surveyor 10/21/13 there was no discharge information in the medical record and no information documented that was sent to the receiving facility on 10/18/13 .

In an interview on 10/24/13 at 9:49 AM with Employee Identifier (EI) # 8, Counselor # 1, she confirmed discharge information was faxed to Teen University. The form Discharge Continuing Care Plan was faxed 10/23/13, at 5:22 PM, which included a comprehensive problem list that required further treatment, diagnoses, medications and discharge to care of Montgomery County DHR (Department of Human Resources). Other recommendations included, "Residential placement for continued emotional and behavioral treatment."

When the surveyor questioned the patient being discharged for 5 days before information was sent, EI # 8 stated that the DHR worker took copies with her 10/18/13 that the original was simply misfiled.

2. MR # 6 was admitted to the facility 9/4/13 with diagnoses of Bipolar Disorder, Substance Abuse and ADHD.

On 9/19/13 the physician ordered, " Culture of right leg, Betadine solution scrub then Triple antibiotic ointment, then cover leg."

The patient's leg wound continued to deteriorate and an order was received 10/6/13 for the Pediatrician to consult regarding wound to right lower leg. The Pediatrician ordered Bactrim DS twice a day for ten days by mouth on 10/6/13. An order was placed in the record 10/7/13 to refer to emergency room for I & D (incision and drainage) on abscess right leg.


The patient had an I & D of the wound 10/7/13. The physician progress note in the medical record 10/7/13 at 11:30 AM documented, " Piece of plastic removed from leg... may be discharged to DHR tomorrow 10/8/13."


The 10/7/13 Multidisciplinary Note the RN documented at 8:45 PM, " Pt has dry dressing to right leg..."


The next entry on the same page was dated 10/8/13 at 8:40 AM, " Pt discharged home to DHR care. Discharge education given. Pt voiced understanding. Pt and guardian educated on discharge medication, also on dressing change to right leg..."


The last order written in the physician orders was on 10/7/13 to refer the patient to the emergency room for the I & D. There are no orders for wound care in the medical record to educate the patient/guardian on discharge.


A copy of the Discharge Continuing Care Plan was reviewed, there is no mention of wound care or follow up post I & D to right leg.

The hospital emergency room discharge instructions have to remove packing in 2 days, this is not included in the Discharge Continuing Care Plan that the DHR worker received on discharge.


The discharge plan failed to cover all of the wound care needs of the patient.


In an interview 10/24/13 at 9:12 AM with EI # 1, the Director of Nursing this information was confirmed.

Based on observation, document review and review of policy and procedure and interviews, the facility failed to provide adequate numbers of Registered Nurses (RNs) to provide nursing care, supervise and monitor patients. The facility's staffing pattern results in limited time for the RN to provide active treatment and limited opportunity to provide direction and supervision of non-professional nursing personnel in the provision of nursing care. The facility's staffing patterns failed to provide adequate numbers of Mental Health Technicians to provide care to the patients to support the treatment plans and meet the patients needs. This had the potential to affect all patients served by this facility.

Findings include:

Policy # 900.200 Staffing, Scheduling of Nursing Service Personnel

I. Purpose
The purpose of this policy is to provide guidelines on scheduling nursing service personnel to meet patient care requirements.

II. Scope
This policy applies to all full time and part time non-exempt direct care giver nursing service personnel (RN's, LPN's, and MH Techs)[ Licensed Practical Nurses and Mental Health technicians].

III. Background/Rationale
Staffing remains a challenge for nurse managers and administrators. It is a never ending balancing act between providing adequate staffing for quality patient care and meeting the bottom line. Schedules frequently have to be changed on short notice because of changes in patient care requirements, illness of a nurse, etc.

C. Flexible Scheduling
DON (Director of Nursing) will evaluate staffing needs based on established grids and criteria and will plan coverage to meet patient/unit need.

Policy # 900.300 Nursing Staffing Plan

I. Purpose:

The Staffing Plan is based on Patient census and acuity. The system reflects the categories of available nursing personnel, infection control standards, safety considerations, unit acuity, method of patient delivery and additional staffing as needed.

II. Policy:

A. Nursing unit will be staffed with RN's, LPN's and MHT's as needed to meet patient needs and allow staff participation in educational and unit meetings.

B. The staffing is reviewed and changes are made as patient volume and acuity dictates at a management level.

Beacon Children's Hospital staffing Matrix revised 4/18/13
Patients= 17-24 for the day shift and night shift 1 RN assigned, 1 LPN assigned and 5 MHTs assigned.

Policy: A100.609
Manual: Administration
Title: High Alert Medication Management
Review Date: 7/23/12

Policy:" Beacon Children's Hospital shall maintain a list of high alert medications (meds) that require specific safeguards to reduce the risk of errors...
High alert meds are drugs that have an increased risk of causing significant harm...special precautions will be employed with their overall management..."

Procedure:

"1. The following are specific medications that require special precautions...
Specific High Alert Drugs:
Insulin
Ativan Injectable
Haldol Deconate
Risperdal Consta

2. Two licensed nurses will verify the dosage and correct medication on each dose of the Specific High Alert Medications listed above."


***

Findings include:

While the surveyors were onsite the census was as follows:

Midnight Census 10/21/13 = 20 patients
Midnight Census 10/22/13 = 21 patients
Midnight Census 10/23/13 = 21 patients
Midnight Census 10/24/13 = 22 patients

A. Observations

Observations occurred 10/23/13 at 10:15 AM by the surveyor:

A new patient arrived to the door where the surveyor was working, accompanied by her mother and the RN from the floor, Employee Identifier (EI) # 12 who directed them to a room across the hall to complete the admission paperwork and assessment.

At approximately 10:45 AM the surveyor observed the LPN from the floor, EI # 13, in the front lobby with a patient being discharged waiting on his family.

There was no nurse on the floor with the patients at this time as the RN was doing the admission and the LPN was in the lobby. EI # 1, the Director of Nursing (DON) was in EI # 3, the Administrator's, office.

The surveyor spoke with EI # 12, the RN at 12:15 PM in the hallway outside the main doors to the unit and she was expecting a second admission to arrive.

An interview was conducted at 12:40 PM on 10/23/13, with EI # 12 regarding the staffing with new patients being admitted. EI # 12 confirmed the floor was left without a nurse earlier while she was doing an admission and the LPN, EI # 13 was off the floor with a discharge.

EI # 12 stated that all new admissions were to be 1:1 for the first 24 hours and now they had two new admissions and the same 5 MHTs they had started with at 7:00 AM. This would remove 2 MHTs from the groups to be occupied with the 1:1 female patients and leave 3 MHTs to work with the groups.

An interview was conducted with EI # 1, the DON on 10/23/13 at 1:55 PM. EI # 1 verified all of the staff work 12 hour shifts and that the typical pattern is 1 RN, 1 LPN and 5 MHTs for both shifts for the number of patients they currently have.

EI # 1 confirmed if a patient is on 1:1 the MHT is dedicated to that patient only. If a MHT is with a patient in restraint another worker is expected to take over the other duties of the MHT.

EI # 1 confirmed that there should not be a time when both nurses are off the floor.

The surveyor asked EI # 1 if she felt staffing was adequate for the facility. EI # 1 stated that they were still doing orientation and trying to hire a pool to keep help available.

The surveyor observed on 10/23/13 at 2:40 PM, patients in the recreation room, two of the new patients who were on 1:1, patients in the dining room and patients outside. The LPN was going back and forth escorting patients to the back hall for telemedicine with the Psychiatrist and staying with the patients to receive orders as needed from the doctor.

The patients returned from outside with the RN and a MHT at 2:50 PM. The floor was again uncovered while both nurses were occupied with patients away from the patient care area.


Medical Record (MR) Findings:


1. MR # 4 was admitted to the facility 10/2/13 with diagnoses including Oppositional Defiant Disorder, Conduct Disorder, Attention Deficit Hyperactivity Disorder (ADHD) and Depression.

On 10/24/13 at 8:49 AM during review of medication records in the med room, the surveyor observed MR # 4 exhibit aggressive behavior.

Phone orders were received for the use of 4 point restraints and Ativan 1 mg (milligram) IM (intramuscularly) stat (now). Verbal report regarding Ativan 1 mg IM stat order was communicated between EI # 11, RN, charge nurse and EI # 10, LPN, med nurse. EI # 10 prepared the high alert drug Ativan in the med room while EI # 11 assisted with MR # 4's restraint application in the time out room.

There was no verification of the specific high alert medication Ativan injectable by two licensed nurses as per facility policy.

Further review of MR # 4's, MAR (Medication Administration Record) revealed Ativan 1 mg IM Stat was administered 10/23/13 at 8:35 PM. The documentation revealed one nurse initialed for the 10/23/13 8:35 PM MAR entry.

MAR documentation failed to include two nurses initials for dosage and correct medication verification of the high alert medication Ativan as per policy.


A 10/24/13 12:10 PM interview with EI # 1, RN, Director of Nurses, who was present during the time MR # 4 was being restrained, validated staff failed to follow the high alert medication management policy during the Ativan preparation.

2. MR # 6 was admitted to the facility 9/4/13 with diagnoses of Bipolar Disorder, Substance Abuse and ADHD.

On 9/14/13 at 9:15 PM, the Interdisciplinary Notes, the RN documented, " Pt insisted to go into the seclusion room and when told there was not staff at this time to sit with him he continued to make threatening statements and refused to walk away from one of the locked doors that he recently kicked in. Another staff member was able to speak with pt and have him move to a chair closer to recreation room where staff could monitor closely."

The Close Observation Flowsheet dated 9/14/13 documented the patient was in time out from 7:30 PM until 9:15 PM at the nurses station.

A review of the daily staffing for 9/14/13 documented one RN, one LPN and 5 MHTs on 7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM.

The facility failed to provide adequate staff to meet the treatment needs of the patients.

These observations revealed that the one RN assigned had duties that included admitting patients, discharging patients, assisting the medication nurse with administering PRN (as needed) medications and verifying high risk medications, meeting with the attending physician during patient rounds or assisting with telemedicine by escorting patients to the room and taking orders from the Psychiatrist during telemedicine, transcribing physician's orders, and answering phones. The RN would leave the floor when doing an admission process and assessment leaving the LPN (Licensed Practical Nurse) to provide medications and oversight of the care the patients were receiving in group therapy and classroom activities. The RN was able to provide limited supervision in providing patient care by the MHT and had very few opportunities to provide active treatment.


In an interview 10/24/13 at 10:00 AM, EI # 1, the DON confirmed the above findings.

Based on review of medical record (MR) and interview, it was determined the nurse failed to:

1. Provide wound care and education to the patient/guardian of specific wound care orders at discharge.

2. To document wound care and skin assessment.

This had the potential to affect all patients served by this agency and did affect MR # 6, one of one patient reviewed with a wound.

Findings include:

1. MR # 6 was admitted to the facility 9/4/13 with diagnoses of Bipolar Disorder, Substance Abuse and ADHD (Attention Deficit Hyperactivity Disorder).

On 9/19/13 the physician ordered, " Culture of right leg, Betadine solution scrub then Triple antibiotic ointment, then cover leg."

The order was transcribed to the MAR (Medication Administration Record) by the nurse to do dressing changes two times a day, there is no frequency on the order from the physician.

The physician's progress note documented 9/20/13 at 8:00 AM, " Small pimple on right leg cultured and cleaned with Betadine."

The Multidisciplinary Note dated 9/20/13 the RN documented at 10:05 AM, " Pt (patient) c/o (complain of) right leg pain, drsg (dressing) to right leg dry and intact, given Motrin 600 mg (milligrams) earlier. Drsg to right side of neck intact and dry."

There is no documented assessment of the wound, size, appearance or drainage documented by the nurse.

The Multidisciplinary Note dated 9/21/13 the RN documented at 8:29 AM,"
Pt c/o right leg pain, 7/10 (pain 7 on 0-10 scale) , refused pain med (medication) at present."

The Multidisciplinary Note dated 9/23/13 the RN documented at 10:25 AM, " Pt insisting to go see a surgeon to remove a piece of a 'plastic knife' that he reports he put deep inside his wound on his right leg. Nurse assessed wound and did not feel anything hard around site. Site does appear infected and is approximately 1.5-2 inches in diameter. Dressing change done to site."

There is no documentation of the physician being notified of the infected wound appearance, no documentation of drainage, wound bed appearance, depth or erythema to the area.

The physician's progress note documented 9/23/13 at 1:10 PM, " Pt (patient) broke piece of plastic and inserted into his leg. Seen by Pediatrician, pt impulsive..."

The 9/24/13 progress note from the physician documented, " Has swelling yellow discharge right leg. X-ray right leg, ER (emergency room consult)."

The 9/25/13 RN Shift assessment for 7:00 AM - 7:00 PM documented, " Right leg- 1 1/2 inch, no drainage, dressing changed wound looks better than it did on assessment on Monday 9/23/13."

The MAR failed to document the dressing was changed to the right leg for the second time on 9/25/13, 9/26/13 and 9/27/13.

The Multidisciplinary Note dated 9/28/13 the RN documented at 8:45 AM," Wound to right calf cleansed with Betadine solution scrub, patted dry, triple antibiotic ointment applied to site and bandage placed. Pt tolerated well, instructed on signs/ symptoms of infection to watch for: fever, edema, erythema, purulent drainage..."

The nurse failed to document an assessment of the wound bed appearance, no documentation of drainage, depth or erythema to the area.

The Multidisciplinary Note dated 9/28/13 the RN documented at 9:45 PM," Wound to right calf noted, swelling marked on leg to be approximately 4-6 cm (centimeters) around area of wound. Wound noted to be 2-3 cm in diameter, mild erythema noted to area, minimum drainage noted..."

There was no documentation the physician was notified of the wound appearance on 9/28/13.

The 10/4/13 progress note from the physician documented, " Right leg wound healing well."

The Multidisciplinary Note dated 10/6/13 the RN documented at 8:20 AM,
" Pt's wound to lower right leg has become worse and is protruding, hard to palpitation and warm in temperature."

The patient's leg wound continued to deteriorate and an order was received 10/6/13 for the Pediatrician to consult regarding wound to right lower leg. The Pediatrician ordered Bactrim DS twice a day for ten days by mouth on 10/6/13. An order was placed in the record 10/7/13 to refer to emergency room for I & D (incision and drainage) on abscess right leg.

The patient had an I & D of the wound 10/7/13. The physician progress note in the medical record 10/7/13 at 11:30 AM documented, " Piece of plastic removed from leg... may be discharged to DHR tomorrow 10/8/13."

The 10/7/13 Multidisciplinary Note the RN documented at 8:45 PM, " Pt has dry dressing to right leg..."

The hospital emergency room discharge instructions state to remove packing in 2 days and Bactrim DS 1 by mouth twice a day for 10 days.

The MAR has a hand written addition 10/8/13 to remove bandage and reapply packing 10/8/13. There is no order for this from the emergency room or the physician at the facility.

The Multidisciplinary Note the RN documented on 10/8/13 at 8:40 AM, " Pt discharged home to DHR (Department of Human Resources) care. Discharge education given. Pt voiced understanding. Pt and guardian educated on discharge medication, also on dressing change to right leg..."

The last order written in the physician orders was on 10/7/13 to refer the patient to the emergency room for the I & D. There are no orders for wound care in the medical record to educate the patient/guardian on discharge.

In an interview 10/24/13 at 9:12 AM with Employee Indentifer (EI) # 1, Director of Nursing confirmed the above information.