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Based on review of the Plan of Correction, audit tools, inservice education through a Skills Fair conducted 11/19/13 and 11/20/13 and interview it was determined the Governing Body failed to ensure the Plan of Correction was followed to include:

1. Staff training and validation of the training

2. Training and education of new staff to be completed within 30 days of hire

3. Auditing of the work load to include staffing daily and the use of the Shift Change Form daily to be turned into the Unit Director.

This had the potential to affect all patients receiving care from the staff in this facility.

Findings include:

1. The plan of correction indicated staff education and training was to be provided starting 11/11/13 and ending 11/20/13. Training to occur on an annual basis thereafter and all new hires were to be trained within 30 days.

A review of the Governing Body Report dated 11/15/13 documented, " Skills Fair dates have been set for 11/19/13 and 11/20/13. These are mandatory for all clinical staff to educate in areas of deficiency and overall education."

The surveyor requested an employee list with dates of hire; any terminated or employees that had resigned were to be identified on the list. The list was received 12/10/13 with a highlighted area of 25 new hires since 10/21/13 through 12/5/13. The list identified 2 terminated employees and 1 resigned employee.

The employee list provided 12/10/13 was utilized to verify the attendance of the Skills Fair conducted 11/19/13 and 11/20/13.

The Skills Fair sign in form for November 19, 2013 had a list of 13 employees attended the 8:00 AM-12:00 noon class and 11 employees attended the 1:00 PM-5:00 PM class.

The Skills Fair sign in form for November 20, 2013 had a list of 12 employees attended the 8:00 AM-12:00 noon class. There was no second class conducted on 11/20/13.

The surveyor reviewed the forms from class attendance and the tests on the items discussed. Several of the tests had dates prior to the class and others had no dates on the tests. There was no documentation the tests had been scored to validate knowledge of the education presented.

A list of 15 staff members from the employee list that had no documentation as having attended the Skills Fair was provided to Employee Identifier (EI) # 1, the Director of Nursing 12/11/13 at 2:10 PM, with a request for information related to their training.

EI # 2, Governing Body representative returned with the list 12/11/13 at 2:50 PM with explanation of why they did not attend. The list had 11 of the 15 who failed to attend the Skills Fair, 3 of these were the Social Worker and 2 counselors who were not scheduled to attend and the teacher making the 4th employee who did not attend. The dates of hire on the employee list provided to the surveyor did not match the employee dates on the response form in 4 employees and 2 voluntary terminations in November did not show on the employee list provided to the surveyor which was to include terminated or resigned employees.

In summary all of the staff did not have documentation of attending the Skills Fair as provided by the hospital in the Plan of Correction and the lack of scored testing did not validate knowledge of the education received.

***

2. On 12/10/13 the employee list was received and a list of employee files was requested to be reviewed.

The employee personnel files were reviewed 12/12/13 at 8:30 AM and the following items were missing:

Nurses without current signed job descriptions-6
Staff without completed orientations forms-15
Staff without current applications- 5
CPR (Cardiopulmonary Resuscitation)-1
CPI (Crisis Prevention Institute) Training- 6
TB (tuberculosis) testing prior to working-2

In an interview with EI # 1, the above information was confirmed.

***

3. The Checklist for Nurses has a section for the AM/PM nurse to initial area which reflect the quality of care, reporting, infection control, Medication Administration recording, checking of expiration dates of medications and other items the Director of Nursing identified to be reviewed daily on each shift. The checklist was to have been implemented 11/8/13 according to the Plan of Correction.

The forms were not completed on the following dates:
11/19/13
11/20/13
11/21/13
11/23/13
11/26/13
11/27/13
No form for 11/28/13
11/29/13
11/30/13
12/1/13
12/2/13
12/3/13
12/4/13
12/5/13
12/6/13
12/7/13
12/8/13
12/10/13

During an interview 12/11/13 at 12:40 PM, EI # 1 reported " the nurses kept the forms and did not turn the forms in at the beginning". EI # 1 validated she had provided the surveyor the shift checklists that had been received from the staff.

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 why patients remained in time out for greater than 30 minutes and what treatment was provided.

3. To document orders for all manual holds and seclusion.

This had the potential to affect all patients in the facility and did affect Medical Record (MR) # 3, # 4 and # 5, 3 of 5 records reviewed.

Findings include:

Policy # A100.309 Time Out revised November 8, 2013.

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 but not to exceed 30 minutes.

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.

Medical Record (MR) findings:

1. MR # 3 was admitted to the facility 11/5/13 with diagnoses of ODD (Oppositional Defiant Disorder), ADHD (Attention Deficit Hyperactivity Disorder) and Mood Disorder.

A review of the time out record dated 11/28/13 documented the following information:
Reason for Time Out- combative/threatening, cussing/ hitting/ yelling at staff.
The patient was in the time out room from 9:00 AM until 9:05 AM.
Least restrictive alternatives implemented:
Other- Gave PRN (as needed)/once combative we used seclusion.

The order for seclusion documents the patient in seclusion from 9:00 AM- 9:05 AM after receiving Benadryl 25 mg (milligrams) IM (Intramuscular) at 9:00 AM.

A review of the time out record dated 11/29/13 documented the following information:
Reason for Time Out- combative/threatening, cussing/ biting/ spitting.
The patient was in the time out room from 1:45 PM until 2:40 PM.
Least restrictive alternatives implemented:
" Other- Pt (patient) was asked to get out of bed and go to Group! Tried talking until pt became combative with staff!"

The patient was in time out greater than 30 minutes on 11/29/13. There was no documentation the physician was consulted and the Multidisciplinary note documented by the nurses failed to indicate the patient had been in time out.

A review of the time out record dated 12/7/13 documented the following information:
Reason for Time Out- Prevent injury to self and prevent injury to others.
The patient was in the time out room from 1500 (3:00 PM) until 1515 (3:15 PM).

A review of the time out record dated 12/7/13 documented the following information:
Reason for Time Out- Pt took time out to get away from another pt to keep from fussing with him.
The patient was in the time out room from 1630 (4:30 PM) until 1715 (5:15 PM).

The patient was in time out greater than 30 minutes on 12/7/13.

A review of a third time out record dated 12/7/13 documented the following information:
Reason for Time Out- Pt wanted a time out cause he was upset about getting a shot and wants to go home.
The patient was in the time out room from 1745 (5:45 PM) until 1815 (6:15 PM).

The Multidisciplinary note documented by the nurses 12/7/13 at 1700 (5:00 PM), " Pt crying, screaming wants to play bowling. Staff unable to get bowling game due to it's locked in Activity Director office. Pt kicking at staff. Benadryl 25 mg IM administered... 1715 (5:15 PM) pt out in hallway talking with staff, calmer at this time. 1725 (5:25 PM) Patients mother ... notified of patients behavior and therapeutic hold verbalized understanding. 1730 (5:30 PM) Pt assessed while therapeutic hold in progress no distress noted."

There was no documentation the physician was consulted regarding the second time out being greater than 30 minutes and multiple time outs used 12/7/13.

A review of the time out record dated 12/8/13 documented the following information:
Reason for Time Out- Prevent injury to self and prevent injury to others.
The patient was in the time out room from 10:00 AM until 10:30 AM.

The Multidisciplinary note documented by the nurses 12/8/13 at 9:15 AM, " Pt requests Vistaril for ' to calm down'. Vistaril 25 mg po ( by mouth) administered. 10:00 AM pt in nurses group, disruptive and unable to redirect- pt to time out at this time...10:30 AM pt back to group, calm, no distress noted."

The medical record Physician Order form failed to document any changed or new orders from 11/29/13 through 12/8/13.

The Treatment plan failed to document any intervention revisions after 12/2/13 for treatment of continued disruptive behaviors requiring time out, seclusion and use of manual holds with medications.

The patient was discharged 12/9/13.

In an interview 12/12/13 at 11:10 AM with Employee Identifier (EI) # 1, the Director of Nursing the above information was confirmed.

2. MR # 4 was admitted to the facility 11/22/13 with diagnoses of ODD and Conduct Disorder.

A review of the time out record dated 12/7/13 documented the following information:
Reason for Time Out-Combative Threatening and prevent injury to others.
The patient was in the time out room from 9:30 AM until 9:45 AM.

The Physician order form for Behavioral Manual Hold, Restraint or Seclusion dated 12/7/13 documented at 9:55 AM, " Clinical reason for restraint or seclusion: Combative/ Threatening, yelling, cursing, attempting to push staff, running, antagonized staff. Therapeutic Hold, Benadryl 25 mg IM at 9:50 AM." Initial telephone order received 12/7/13 at 10:55 AM.

The patient came out of the first time out 12/7/13 at 9:45 AM and went into a Manual Hold 9:55 AM until 10:20 AM per time entered on Restraint status form.

A review of the second time out record dated 12/7/13 documented the following information:
Reason for Time Out-Prevent injury to self and prevent injury to others.
The patient was in the time out room from 11:25 AM until 11:40 AM.

The Multidisciplinary note documented by the nurses 12/7/13 at 9:15 AM, " Pt. getting up in group, antagonizing other residents and getting others aggravated...9:30 AM, Pt took time out. 9:45 AM pt started yelling, cursing, attempting to push staff out of way. 9:50 AM, PRN Benadryl given IM left buttock. 9:55 AM Placed in manual hold due to swinging at staff. 10:08 AM pt reentered group without problems or incidents noted."
12/7/13 late entry-"9:44 AM- Vistaril 25 mg po administered due to pt complaint of anxiety and becoming aggressive with staff."

The Multidisciplinary note documented by the nurses 12/7/13 at 18:05 (6:05 PM)," Benadryl 25 mg IM adminstered to right gluteal due to aggressive behavior. Pt kicking and hitting at staff and slamming his hands against dispenser. 1835 (6:35 PM) pt back to TV (television) room and sitting in the corner. 1840 (6:40 PM) pt continues to sit in TV room at this time assessed while in manual hold with no problems noted..."

There was no Physician order form for Behavioral Manual Hold, Restraint or Seclusion dated 12/7/13 for a second Manual Hold.

A review of the time out record dated 12/8/13 documented the following information:
Reason for Time Out-Prevent injury to self and prevent injury to others.
The patient was in the time out room from 9:13 AM until 9:32 AM.

The intervention revisions made on the Interdisciplinary Treatment Plan (ITP) due to the multiple episodes of time out were as follows:
" 12/2/13 encourage self soothing techniques failed...
12/7/13 administer PRN as ordered
12/7/13 will assess and offer therapeutic alt. (alternative) activities
12/8/13 encourage to talk to staff to de-escalate."

In an interview with EI # 1 on 12/12/13 the question was asked what did the staff do for a new intervention with all of the behavior problems MR # 4 continued to exhibit. EI # 1 stated that they updated the ITP to administer PRN's and ask the patient to talk to staff.

In an interview 12/12/13 at 11:00 AM with EI # 1, the above information was confirmed.



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3. MR # 5 was admitted to the facility 11/13/13 with diagnoses including Oppositional Defiant Disorder, Conduct Disorder and Mood Disorder Not Otherwise Specified.

Review of the 12/1/13 8:58 AM Initial Phone Orders for Behavioral Manual Hold, Restraint or Seclusion revealed patient behaviors were hitting, kicking staff and threatening staff. Manual Hold was documented 12/1/13 at 8:58 AM with Benadry 25 mg IM given at 9:00 AM, Haldol 2 mg IM and Ativan 1 mg IM administered at 9:20 AM.

Review of the 12/1/13 Continuous in-person monitoring revealed 9:00 restraint status 1- MH (manual hold), 9:15 1-MH and 9:25 2 (out of restraints).

Review of the 12/1/13 Close Observation Flowsheet documentation 8:45 AM to 9:30 AM revealed the patient was in the "SR" seclusion room. The 12/1/13 8:58 AM physician's order was for Manual Hold. There was no physician's order for seclusion room placement as documented 12/1/13 8:45 AM to 9:30 AM.

An interview 12/11/13 at 11:40 AM with EI # 1 verified the times for Manual Hold and Close Observation Flowsheet did not match. There was no physician's order for use of the seclusion room as documented on the 12/1/13 Close Observation Flowsheet.

Based on review of medical records, Medication Administration Records (MARs), policies and procedures, interviews and Standards of Practice it was determined the nurse failed to:

1. Follow the physician's order for medication as written.

2. Transcribe the medication as ordered to the MAR correctly.

3. Document the results and/or effectiveness of PRN (as needed) medications.

4. Follow the route of the medication order.

5. Follow the policy for Medication Administration Record.

This had the potential to affect all patients served by this facility and did affect Medical Record (MR) # 1, # 3, # 4, # 5 and unsampled MR's # 6 and # 7.

Alabama Board of Nursing Chapter 610-X-6
Standards of Nursing Practice

610-x-6-.07 Medication Administration and Safety

" (1) The registered nurse or licensed practical nurse shall have applied knowledge of medication administration and safety, including but not limited to:
(a) Drug action
(b) Classifications
(c) Expected therapeutic benefit of medication
(d) Expected monitoring
(e) Indications based on existing patient illness or injury processes.
(g) Possible side effects and interventions for same.
(j) Safety precautions including but not limited to:
(i) Right patient
(ii) Right medication
(iii) Right time
(iv) Right dose
(v) Right route
(vi) Right reason
(vii) Right documentation
(2) The registered nurse or licensed practical nurse shall exercise decision making skills when administering medications, to include but not limited to:
(a) If medication should be administered.
(b) Assessment of patient's health status and complaint prior to and after administering medications including PRN medications.
(c) When to contact the prescriber.
(3)The registered nurse or licensed practical nurse shall exhibit skills when administering medications including but not limited to:
(f) Routes of administration.
(4) Documentation of medication administration shall comply with the principles of documentation and include safety precautions of medication administration, controlled drug records per federal and state law and facility policy."

Policy and Procedure A 100.603 revised November 7, 2013
Medication Administration Record

Policy: Beacon Children's Hospital will provide a complete and permanent record of the transcription and documentation of all medications through the use of a MAR.

Procedure:
3. The nurse will verify the MAR with the physician's orders and sign it.
4. New orders written during the day, before a new MAR is issued, will be added to the MAR by the Nurse signing off the order and will " highlight" out discontinued orders.
10. Documentation of therapeutic response to PRN (as needed) medications should be documented on the back of the MAR.

Policy and Procedure
Policy Number A100.609
Review Date 11/7/13
Title: High Alert Medication 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 and Procedure
Policy Number A100.600
Review Date 11/7/13
Title: Medication Administration

General Information
"...8. Drugs Ordered by More than one Route
a. The medication should be transcribed seperately for each route...
Documentation
...2. The nurse will sign initials in the designated block that corresponds to the time the nurse administered the medications during the assigned shift.
...5. All responses to PRN medications administered...should be documented on the back of the MAR (medication administration record)...
6. Drugs administered via the IM (intramuscular) route should have an injection site noted on the space next to the time/initials.
...The RN (Registered Nurse)/LPN (Licensed Practical Nurse) will check the MAR at the end of the shift to be sure all dose were properly charted".


Medical Record (MR) findings:

1. MR # 1 was admitted to the facility 11/14/13 with a presenting problem of Suicidal Ideations and Depression.

The admission orders dated 11/14/13 included:

Vistaril 25 mg (milligrams) PO ( by mouth) q8h (every 8 hours) PRN for agitation/insomnia.
Benadryl 25 mg IM q8h PRN for agitation/insomnia.

The MAR for November 2013 included under medications:
Vistaril 25 mg IM/PO q 8 h PRN agitation/insomnia.
Benadryl 25 mg PO/IM q8h PRN for agitation/insomnia.

The transcription of the medication order has the incorrect route documented.

The front section of the MAR documented Vistaril 25 mg IM/PO administered 11/22/13 and 11/23/13. The back of the MAR only documented Vistaril 25 mg PO at 2020 (8:20 PM) on 11/22/13. The nurse failed to document the results/response to the medication on the MAR.


The nurse failed to document the 11/23/13 dose of Vistaril on the back of the MAR. The time of administration is not known and the response to the medication is not known. There was no documentation in the nurses notes of either PRN medication of Vistaril being administered and whether it was given for agitation or insomnia.


The front section of the MAR documented Benadryl 25 mg PO/IM administered 11/29/13. The back of the MAR documented Benadryl 25 mg IM administered at 12:40 PM for agitation. There was no documentation in the nurses notes of the patient requiring Benadryl IM for agitation.


In an interview with Employee Identifier (EI) # 1, Director of Nursing, on 12/12/13 at 10:45 AM the above information was confirmed.

2. MR # 4 was admitted to the facility 11/22/13 with diagnoses of ODD (Oppositional Defiant Disorder) and Conduct Disorder.

The admission orders dated 11/22/13 at 11:00 AM included:

Vistaril 25 mg (milligrams) PO ( by mouth) q8h (every 8 hours) PRN for anxiety/agitation.
Benadryl 25 mg IM (intramuscular) q8h PRN for agitation/insomnia.

The MAR for November 2013 included under medications:
Vistaril 25 mg PO q 8 h for anxiety & agitation as needed.
Vistaril 25 mg IM q 8 h for anxiety & agitation as needed.

Benadryl 25 mg PO/IM q8h PRN for agitation/insomnia.

The transcription of the medication order has the incorrect route documented.

The front section of the MAR documented Vistaril 25 mg IM/PO administered 11/23/13, 11/24/13, 11/25/13, 11/26/13, 11/28/13 and 11/29/13. The back of the MAR only documented:
Vistaril 25 mg PO at 2120 (9:20 PM) on 11/23/13 for insomnia. The nurse failed to document the results/response to the medication on the MAR. The patient did not have Vistaril ordered for insomnia.

Vistaril 25 mg PO at 12:05 PM on 11/24/13 for anxiety prior to nap.

Vistaril 25 mg PO at 1952 (7:52 PM) on 11/24/13 for agitation. The nurse failed to document the results/response to the medication on the MAR. This second dose of Vistaril is not documented as administered on the front of the MAR.

Vistaril 25 mg PO at 10:32 AM on 11/25/13 for agitation. The nurse failed to document the results/response to the medication on the MAR.

Vistaril 25 mg PO at 2005 (8:05PM) on 11/26/13 for insomnia. The nurse failed to document the results/response to the medication on the MAR. The patient did not have Vistaril ordered for insomnia.

Vistaril 25 mg PO on 11/28/13 for insomnia/agitation. There was no time documented the medication was administered.

The front section of the MAR documented Benadryl 25 mg IM administered 11/24/13, 11/29/13 and 11/30/13.
The back of the MAR only documented:
Benadryl 25 mg IM at 1448 (2:48PM) on 11/24/13 for aggressive behavior. The Benadryl was ordered for agitation and insomnia.

In an interview with EI # 1, Director of Nursing, on 12/12/13 at 11:00 AM the above information was confirmed.

3. MR # 3 was admitted to the facility 11/5/13 with diagnoses of ODD, ADHD (Attention Deficit Hyperactivity Disorder) and Mood Disorder.

The admission orders dated 11/5/13 at 2000 (8:00 PM) included:

Vistaril 25 mg PO/IM q8h PRN for agitation/ insomnia.

The MAR for November 2013 included under medications:
Vistaril 25 mg PO/IM q 8 h PRN agitation/insomnia.

The back of the MAR documented Benadryl 25 mg IM given 11/9/13 and 11/10/13 for agitation. The front of the MAR did not have Benadryl as a medication to be administered for agitation until 11/13/13.

The MAR had a hand written addition for Benadryl 25 mg IM q8h PRN agitation with the first dose documented as given 11/13/13 on the front and on the back the nurse documented, " Vistaril replaced with Benadryl 25 mg IM agitation at 2000 (8:00 PM)." The nurse failed to
document the results/response to the medication on the MAR.

The MAR documented the patient received Benadryl 25 mg IM for agitation on 11/16/13, twice on 11/17/13 and 11/30/13 with no documented results/ response to the medication on the MAR.

The December MAR included Benadryl 25 mg IM q8h PRN agitation or insomnia ordered 11/14/13.

The MAR documented the patient received Benadryl 25 mg IM for agitation 12/1/13 at 1600 (4:00 PM) with no documented results/ response to the medication on the MAR. The Order form for Behavioral Manual Hold, Restraint or Seclusion documented 12/1/13 at 1600 medications adminstered, " Benadryl 12.5 mg IM left gluteal at 1600." This documentation does not match the MAR which has 25 mg not 12.5 mg.

The Order form for Behavioral Manual Hold, Restraint or Seclusion documented 12/2/13 at 7:00 AM medications administered, " Benadryl 12.5 mg IM."

The MAR documented the patient received Benadryl 12.5 mg IM for agitation 12/1/13 and 12/2/13 with no order to decrease the dose and no one time orders transcribed to the MAR.

The physician failed to date and time the signature on orders for Behavioral Hold, restraint or seclusion forms on the following days:
The order for 11/22/13 at 1550 (3:50 PM) was dated 11/26/13 for the physician signature and a separate order for 11/22/13 at 2150 (9:50 PM) was dated 11/26/13 for the physician signature. Physician failed to sign and date for the following dates 11/28/13, 11/29/13, 12/1/13, 12/2/13, and 12/7/13.


In an interview with EI # 1, Director of Nursing, on 12/12/13 at 11:10 AM the above information was confirmed.




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4. MR # 5 was admitted to the facility 11/13/13 with diagnoses including Oppositional Defiant Disorder, Conduct Disorder and Mood Disorder Not Otherwise Specified.

Review of MR # 5's Medication Record orders included Benadryl 25 mg IM q 8 hours prn and Vistaril 25 mg q 8 hours IM/PO. Benadryl 25 mg IM was administered 11/17/13. Review of the backside of MR # 5's Medication Record Nurse's Note failed to include the site of the 11/17/13 Benadryl administration or the results/response to the Benadryl . There was no documentation on the 11/17/13 RN shift assessment note for Benadryl administration. The orders for Vistaril IM and PO were not transcribed separately as per facility policy.

Review of MR # 5's 11/18/13 Medication Record administration included Benadryl 25 mg IM. Review of the backside of MR # 5's Medication Record Nurse's Medication Notes failed to include results/response to the Benadryl. Review of 11/18/13 RN shift assessment note documentation failed to include the Benadryl administration. Further review revealed an 8:35 AM 11/18/13 order for Haldol 2 mg po or IM x 1 now. There was only 1 nurse initials for the high alert drug, Haldol, administered 8:30 AM on 11/18/13. The Haldol IM and PO route was not transcribed separately onto the MAR.

Review of MR # 5's Medication Record administration included an entry dated 11/19/13 4:00 PM for Benadryl 25 mg IM, initialed by the nurse. Review of the backside of MR # 5's Medication Record failed to include results/response to the 11/19/13 Benadryl 25 mg IM administration. The 11/19/13 RN shift assessment documentation and Medication Record failed to reveal the site of the IM Benadryl.

Review of MR # 5's Medication Record included Vistaril 25 mg q 8 hr prn IM/PO. Review of the backside of MR # 5's Medication Record Nurse's Medication Notes contained an entry dated "...11/20/13 0705 (7:05 AM) for Vistaril 25 mg po increased agitation." There were no nurse initials to reveal who administered the 11/20/13 7:05 AM Vistaril and no results/response to the Vistaril documented.

Review of MR # 5's 11/22/13 7:05 AM Medication Record administration revealed Vistaril 25 mg po was given for increased agitation. There was no documentation of the results/response to the Vistaril.

Review of Physician's orders dated 11/25/13 11:51 AM revealed Haldol 2 mg IM x (for) 1 dose. There was no 11/25/13 11:51 AM Medication Record entry for the Haldol order. Further review revealed the following documentation on the Medication Record administration Nurse's Notes: "...11/25/13 Haldol 2 mg IM x 1 now-cursing, biting, trying to spit on staff-(nurse initials)...." The 11:25 11:51 AM Haldol order was not transcribed onto MR # 's 5 Medication Record. There was no documentation of the administration site for the Haldol. There was no documentation of the Haldol results/response included in the Nurse's Medication Notes.

Review of 11/28/13 Orders for Behavioral Manual Hold, Restraint or Seclusion Physician Orders document contained the following: "...16:15 (4:15 PM)...Chemical Restraint: Ativan, Benadryl...Medications Administered..." There was no documentation of the dosage or administration site for Ativan and Benadryl used during the 11/28/13 chemical restraint intervention.

Review of MR # 5's 11/30/2013 Medication Record administration revealed Ativan 1 mg and Haldol 2 mg IM were given for combative behaviors. There was no documentation that 2 nurses verified the high alert medication dosages requirement as per facility policy. There were initials documented for only 1 nurse for the 11/30/13 Ativan and Haldol preparation.

An interview, conducted 12/12/13 at 11:20 AM with EI # 1, Director of Nurses, verified the above findings.

5. During a 12/12/13 10:30 AM tour of the nursing unit, the surveyor reviewed the current patient's Medication Record administration documents, including unsampled MR's # 6 and # 7. The following documentation was revealed:

Unsampled MR # 6 was admitted to the facility 12/4/13. The Medication Record administration document diagnoses included Defiant and Aggression. PRN medications ordered included Ibuprofen 600 mg tab 1 po every 6 hours after meals as needed, date 12/5/13 and Naproxen 375 mg 1 po bid (twice daily) prn, date 12/5/13.

Review of medications administered 12/10/13 included Ibuprofen, initialed by the nurse. Review of the backside of the Nurse's Medication Notes failed to include documentation the Ibuprofen was administered including the date/hour, medication/dosage, reason and results/response of the Ibuprofen.

Further review of unsampled MR # 6's 12/11/13 medication administration documentation revealed Naproxen 375 mg 1 po bid prn was given as initialed by the nurse on 12/11/13. Review of the backside of the Nurse's Medication Notes failed to include documentation Naproxen was administered including the date/hour, medication/dosage, reason and results/response of the Naproxen.

7. Unsampled MR # 7 was admitted to the facility 12/3/13. The Medication Record administration document diagnosis included Defiance. PRN medications ordered included Vistaril 25 mg 1 capsule po every 8 hours as needed for agitation, date 12/4/13.

Review of medications administered 12/10/13 included Vistaril, initialed by the nurse. Review of the backside of the Nurse's Medication Notes failed to include results/response of the Vistaril.

Based on review of medical record, policy and procedure and interview it was determined the facility staff failed to:

1. Sign the Level System Behavior Sheet Tracking sheet in 4 of 5 records reviewed.

This had the potential to affect all patients served in the facility related to what team they would be placed on to document improvement and meeting the goals toward discharge.

2. Document Pediatric consultation visits as ordered.

3. Document completion of the Shift Change Form and forward to the Unit Director daily to be implemented 11/8/13.

This had the potential to affect all patients served in this facility and did affect Medical Record (MR's) # 1, # 3, # 4 and # 5.


Policy:
It shall be the policy of Beacon Children's Hospital to assign each patient to a level based on his/her daily behavior, with Level 0 being the lowest and level 3 being the highest.

Purpose:
This policy exists in order to reward patients for positive behaviors and give patients incentives to stop negative behaviors and follow the rules of the facility.

Procedure:
1. The Beacon Children's Hospital Level System Behavior Tracking Sheets will be used to document patient's behavior through each activity throughout the day. Each patient should be given points (on a 0 to 5 scale, 0= no participation/ inappropriate behavior to 5= full participation/appropriate behavior) based on their participation and behaviors during each activity. A patient's level depends on the total number of points earned each day. Each patient's Level System Behavior Tracking Sheet will be kept with their flow sheet.

2. The Beacon Children's Hospital Level System Behavior Tracking Sheets will be collected on Monday, Wednesday and Friday morning and scores tallied to determine which, if any, patients have earned promotion to a higher level or demotion to Level 1.

3. A patient will be on Level 0 when on 1:1 observation.

The above policy was received from Employee Identifier (EI) # 1, Director of Nursing 12/11/13 at 3:30 PM. The use of the Level system is intergral to the staffing matrix used by the nurses and Director of Nursing to staff the unit.

Medical Record Findings:

1. MR # 1 was admitted to the facility 11/14/13 with a presenting problem of Suicidal Ideations and Depression.

The Physician's Order sheet had documentation 12/5/13 at 4:30 PM, " Consult Ped (pediatrician) for dry cough/bronchitis."

There was no documentation in the medical record to confirm the Pediatrician examined MR # 1 after the order 12/5/13.

The Physician's Order sheet had documentation 12/11/13 at 11:00 AM, " Consult Ped."

There was no documentation in the medical record to confirm the Pediatrician examined MR # 1 after the order 12/11/13.

In response to questions regarding documentation of the Pediatrician consult visits and E-mail was recieved from EI # 2, Governing Body, 12/13/13 which stated, " Pediatric consult notes cannot be located within the medical record."

A review of the medical record documentation on the Level System Behavior Tracking Sheets revealed the facility staff failed to sign the forms 11/23/13, 11/24/13, 11/26/13, 11/29/13, 11/30/13, 12/1/13, 12/2/13, 12/3/13, 12/4/13, 12/5/13, 12/6/13, 12/7/13 and 12/8/13.

In an interview 12/12/13 at 10:45 AM with EI # 1, Director of Nursing the above information was confirmed.

2. MR # 3 was admitted to the facility 11/5/13 with diagnoses of ODD (Oppositional Defiant Disorder), ADHD (Attention Deficit Hyperactivity Disorder) and Mood Disorder.

A review of the medical record documentation on the Level System Behavior Tracking Sheets revealed the facility staff failed to sign the forms 11/23/13, 11/24/13, 11/26/13, 11/28/13, 11/29/13, 11/30/13, 12/1/13, 12/2/13, 12/3/13, 12/4/13, 12/5/13, 12/6/13, 12/7/13 and 12/8/13.

In an interview 12/12/13 at 11:10 AM with EI # 1, Director of Nursing the above information was confirmed.

3. MR # 4 was admitted to the facility 11/22/13 with diagnoses of ODD and Conduct Disorder.

A review of the medical record documentation on the Level System Behavior Tracking Sheets revealed the facility staff failed to sign the forms 11/23/13, 11/24/13, 11/26/13, 11/27/13 11/28/13, 11/29/13, 11/30/13, 12/1/13, 12/2/13, 12/3/13, 12/7/13 and 12/8/13.

In an interview 12/12/13 at 11:00 AM with EI # 1, Director of Nursing the above information was confirmed.



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4. MR # 5 was admitted to the facility 11/13/13 with diagnoses including Oppositional Defiant Disorder, Conduct Disorder and Mood Disorder Not Otherwise Specified.

A review of the medical record documentation on the Level System Behavior Tracking Sheets revealed staff failed to sign the forms on 11/24/13, 11/28/13, 11/30/13 and 12/2/13.

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

1. Ensure all medication orders were complete

2. Ensure the route of medication administration was specified

3. Ensure the medications were adminstered as ordered

4. Ensure the physician signed the orders within 48 hours per policy.

This had the potential to affect all patients served by this facility and did affect Medical Record # 1, # 3, # 4 and # 5.

Findings include:

Facility Policy: Physician's Orders

Policy: Physicians' orders will be written on an as-needed basis by the attending physician or any member of the Medical staff.

Procedure: During rounds or on an as-needed basis, patients will be evaluated regarding progress to Treatment Plan or for medical issues and orders will be changed on an as-needed basis.

A. Orders may be written, verbal or by telephone.

B. All verbal and telephone orders will be verified by read back by staff taking the order and noted on the order sheet.

C. Authentication of verbal orders may be obtained via a faxed copy of the original order with physician's signature. Authenication must include date and time order was signed.

D. Verbal and telephone orders must be authenticated within forty-eight hours, in accordance with CMS (Centers for Medicare and Medicaid) guidelines.


Medical record findings include:

1. Medical Record (MR) # 1 was admitted to the facility 11/14/13 with a presenting problem of Suicidal Ideations and Depression.

The admission orders for the Physician were documented by the nurse as a verbal order 11/14/13 at 1748 (5:48 PM). The Physician co-signed the order without documenting a date or time.

2. MR # 3 was admitted to the facility 11/5/13 with diagnoses of ODD (Oppositional Defiant Disorder), ADHD (Attention Deficit Hyperactivity Disorder) and Mood Disorder.

The physician failed to date and time the signature on orders for Behavioral Hold, restraint or seclusion forms on the following days:
12/7/13, 12/2/13, 12/1/13, 11/29/13, 11/28/13, the order for 11/22/13 at 1550 (3:50 PM) was dated 11/26/13 for the physician signature and a seperate order for 11/22/13 at 2150 was dated 11/26/13 for the physician signature.

3. MR # 4 was admitted to the facility 11/22/13 with diagnoses of ODD and Conduct Disorder.

The physician failed to date and time the signature on orders for Behavioral Hold, restraint or seclusion forms on 12/7/13.

4. MR # 5 was admitted to the facility 11/13/13 with diagnoses including Oppositional Defiant Disorder, Conduct Disorder and Mood Disorder Not Otherwise Specified.

Review of the 11/30/13 6:02 PM Behavioral Hold, restraint or seclusion form did not contain the name and professional title of the clinician who received the Manual Hold or Benadryl, Ativan and Haldol order from the physician.

The physician failed to date and time the signature on orders for Behavioral Hold, restraint or seclusion forms on the following days: 11/17/13, 11/20/13, 11/28/13, 11/30/13 2:45 PM, 11/30/13 6:02 PM and 12/1/13.

An interview, conducted 12/12/13 at 11:20 AM with EI # 1, confirmed the above findings.

Based on a review of medical records and interview it was determined the facility failed to update the treatment plans and discharge criteria goals when the patients continued to exhibit behavior requiring restraint/ seclusion, time outs and the use of PRN (as needed) medications. This had the potential to affect all patients covered by this facility and did affect Medical record (MR) # 3 and # 4, 2 of 5 medical records reviewed.


Findings include:

1. MR # 3 was admitted to the facility 11/5/13 with diagnoses of ODD (Oppositional Defiant Disorder), ADHD (Attention Deficit Hyperactivity Disorder) and Mood Disorder.

The Master Treatment Plan documented the following as active Problems 11/8/13:
1. ODD/ Conduct Disorder- Paternal neglect.
2. ADHD by history.
3. Mood disorder.
4. Enuresis

Problem # 1- ODD included the short term objectives:
" a. will learn at least coping techniques that could be used to decrease anger before becoming aggressive... date completed 12/6/13.
c. will identify triggers that led to kicking and biting his teacher...date completed 11/14/13."

Problem # 3 Mood Disorder included the following Short Term Objectives:
" b. will identify and process negative coping skills such as kicking and biting and process better ways to cope when he becomes agitated- date completed 12/6/13."

A review of the time out record dated 12/7/13 documented the following information:
Reason for Time Out- Prevent injury to self and prevent injury to others.
The patient was in the time out room from 1500 (3:00 PM) until 1515 (3:15 PM).

A review of the time out record dated 12/7/13 documented the following information:
Reason for Time Out- Pt (patient) took time out to get away from another pt to keep from fussing with him.

The patient was in the time out room from 1630 (4:30 PM) until 1715 (5:15 PM).

The patient was in time out greater than 30 minutes on 12/7/13.

A review of a third time out record dated 12/7/13 documented the following information:
Reason for Time Out- Pt wanted a time out cause he was upset about getting a shot and wants to go home.

The patient was in the time out room from 1745 (5:45 PM) until 1815 (6:15 PM).

The Multidisciplinary note documented by the nurses 12/7/13 at 1700 (5:00 PM), " Pt crying, screaming wants to play bowling. Staff unable to get bowling game due to it's locked in Activity Director office. Pt kicking at staff. Benadryl 25 mg (milligrams) IM (Intramuscular) administered... 1715 (5:15 PM) pt out in hallway talking with staff, calmer at this time. 1725 (5:25 PM) Patients mother ... notified of patients behavior and therapeutic hold verbalized understanding. 1730 (5:30 PM) Pt assessed while therapeutic hold in progress no distress noted."

There was no documentation the physician was consulted regarding the first time out greater than 30 minutes and multiple time outs used 12/7/13.

A review of the time out record dated 12/8/13 documented the following information:
Reason for Time Out- Prevent injury to self and prevent injury to others.
The patient was in the time out room from 10:00 AM until 10:30 AM.

The Multidisciplinary note documented by the nurses 12/8/13 at 9:15 AM, " Pt requests Vistaril for ' to calm down'. Vistaril 25 mg po ( by mouth) administered. 10:00 AM pt in nurses group, disruptive and unable to redirect- pt to time out at this time...10:30 AM pt back to group, calm, no distress noted."

The medical record Physician Order form failed to document any changed or new orders from 11/29/13 through 12/8/13.

The Treatment plan failed to document any intervention revisions after 12/2/13 for treatment and had documented a completion date of 12/6/13 related to behaviors in ODD and Mood Disorder plans. The patient continued to exhibit disruptive behaviors requiring time out, seclusion and use of manual holds with medications on 12/7/13 and 12/8/13 prior to the discharge 12/9/13.

In an interview 12/12/13 at 11:10 AM with Employee Identifier (EI) # 1, Director of Nursing the above information was confirmed.

2. MR # 4 was admitted to the facility 11/22/13 with diagnoses of ODD and Conduct Disorder.

The Master Treatment Plan documented the following as active Problems 11/27/13:
1. ODD/ Conduct Disorder- running away from school and home several times, fighting, profanity, urinates on walls.
2. ADHD combined.

Problem # 1 ODD/ Conduct Disorder included the following Short Term Objectives:
" a. will learn at least coping techniques that could be used to decrease anger before becoming aggressive... - date completed 12/2/13.
c. will identify triggers that led to being disrespectful at school which led him to be restrained- date completed 12/2/13.
i. will refrain from leaving out of group without permission and if he needed a PRN or a time out get permission before leaving out of group setting- target date 12/6/13. "


A review of the time out record dated 12/7/13 documented the following information:
Reason for Time Out-Combative Threatening and prevent injury to others.
The patient was in the time out room from 9:30 AM until 9:45 AM.

The Physician order form for Behavioral Manual Hold, Restraint or Seclusion dated 12/7/13 documented at 9:55 AM, " Clinical reason for restraint or seclusion: Combative/ Threatening, yelling, cursing, attempting to push staff, running, antagonized staff. Therapeutic Hold, Benadryl 25 mg IM at 9:50 AM." Initial telephone order received 12/7/13 at 10:55 AM.

The patient came out of the first time out 12/7/13 at 9:45 AM and went into a Manual Hold 9:55 AM until 10:20 AM per time entered on Restraint status form.

A review of the second time out record dated 12/7/13 documented the following information:
Reason for Time Out-Prevent injury to self and prevent injury to others.
The patient was in the time out room from 11:25 AM until 11:40 AM.

The Multidisciplinary note documented by the nurses 12/7/13 at 9:15 AM, " Pt. getting up in group, antagonizing other residents and getting others aggravated...9:30 AM, Pt took time out. 9:45 AM pt started yelling, cursing, attempting to push staff out of way. 9:50 AM, PRN Benadryl given IM left buttock. 9:55 AM Placed in manual hold due to swinging at staff. 10:08 AM pt reentered group without problems or incidents noted."
12/7/13 late entry-"9:44 AM- Vistaril 25 mg po administered due to pt complaint of anxiety and becoming aggressive with staff."

The Multidisciplinary note documented by the nurses 12/7/13 at 18:05 (6:05 PM)," Benadryl 25 mg IM administered to right gluteal due to aggressive behavior. Pt kicking and hitting at staff and slamming his hands against dispenser. 1835 (6:35 PM) pt back to TV (television) room and sitting in the corner. 1840 (6:40 PM) pt continues to sit in TV room at this time assessed while in manual hold with no problems noted..."

There was no Physician order form for Behavioral Manual Hold, Restraint or Seclusion dated 12/7/13 for a second Manual Hold.

A review of the time out record dated 12/8/13 documented the following information:
Reason for Time Out-Prevent injury to self and prevent injury to others.
The patient was in the time out room from 9:13 AM until 9:32 AM.

The intervention revisions made on the Interdisciplinary Treatment Plan (ITP) due to the multiple episodes of time out were as follows:
" 12/2/13 encourage self soothing techniques failed...
12/7/13 administer PRN as ordered
12/7/13 will assess and offer therapeutic alt. (alternative) activities
12/8/13 encourage to talk to staff to de-escalate."

The Treatment plan documented the patient had met the goal 12/2/13 for coping with his aggressive behavior and anger. The patient continued to exhibit disruptive behaviors requiring time out and use of manual holds with medications on 12/7/13 and 12/8/13.

In an interview with EI # 1 on 12/12/13 the question was asked what did the staff do for a new intervention with all of the behavior problems MR # 4 continued to exhibit. EI # 1 stated that they updated the ITP to administer PRN's and ask the patient to talk to staff.

In an interview 12/12/13 at 11:00 AM with EI # 1, the above information was confirmed.