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Based on interview and document review the facility failed to protect the rights and failed to insure the nursing staff identified and met the needs of 1 of 1 patients identified.

On 12/6/2012 the medical record (MR) for patient (pt) #1 was reviewed and revealed
the following: Pt #1 was a 59 year old man who was transferred from an acute care hospital with dementia combined with psychosis. The receiving facility was aware of Pt #1 psychosis which contributed to his severe confusion and volatile behavior through the documentation from the acute care nursing staff and medical staff notes. While in the acute hospital Pt #1 had become agitated and thrown medical equipment at the nursing staff.

On 12/6/2012 at 9:30 AM an interview with the staff #2 confirmed she was familiar with pt #1. Staff #2 indicated she had functioned as the admissions coordinator and had admitted pt #1. She recalled pt #1 was very violent while in the acute setting.

On 12/6/2012 at 9:30 AM an interview with the administrator confirmed that when the medication wore off of pt #1 he was wild if he became agitated.

On 12/6/2012 at 10:00 AM a review if pt #1 MR revealed the following. Upon admission to the behavioral health hospital, all acute hospital prescription medication were continued, this included Geodon 10 milligrams (mg) IM (intramuscularly) every 6 hours as needed (PRN) for agitation. This order, from the physician, had no parameters set for agitation. Agitation was left to the judgment of the nursing staff.

The first dose of Geodon was documented as given by the nursing staff at 0440 hrs (military time). A review of the MR for pt #1 revealed the Mental Health Tech (MHT) documented every 15 minutes on pt #1. The MHT documented no aggressive or agitated behaviors for the first 24 hours after admission. The first shift, daily nursing assessment did not reflect agitated or aggressive behavior for either the 0440 hr dose or the 2215 hr dose which followed. Nursing Medication Effectiveness Form indicated 9/6/2012 at 0440 Geodon 10 mg IM was given for increased agitation which was effective after one hour. At 2215 the documentation reads the same. There was no other nursing documentation to explain the uses of the Geodon 10 mg. IM.

Further review revealed 9/7/2012 0145 a "Night time sleep aid of 50 mg" was given by mouth for insomnia and was effective with decreased insomnia after one hour. On 9/7/2012 at 0555 Geodon 10 mg by mouth was given for agitation and effective after one hour to decrease the agitation. Then on 9/7/2012 at 1200 noon Geodon 10 mg IM was given for increased agitation and this was effective to decrease the agitation after two hours. There was no other nursing documentation to explain the trigger for the agitation, the interventions attempted by the MHT and nursing staff prior to the use of IM Geodon. The MHT every 15 minute documentation record no agitation or aggression for 24 hours. This pattern is established for 16 doses of IM Geodon, 1 dose of IM Ativan 1 mg and 2 IM doses of Haldol 10 mg.

Pt #1 received Geodon 10 mg IM on, 9/6/12 at 0440 and 2215 PM, 9/7/2012 at 0550 and 1200, 9/8/2012 0010 and 1100, 9/9/ at 1030 and 2315, 9/1/2012 0050, 9/15/2012 at 1215, 9/16/2012 at 0505, 9/21/2012 at 1100 and 1700, 9/22/20 12 0915, 1600 and at 2300, 9/23/2012 1600. On 9/22/2012 pt #1 received Haldol 10 mg IM at 0915 and 1600, and on 9/23/2012 pt #1 received Haldol 10 mg IM at 0930. Further review of pt #1 MR revealed there was no physician evaluation for pt #1 agitated behavior. There was no physician evaluation of pt #1 for any physical behavior. There was no nursing assessment of the patient behaviors, interventions that were attempted prior to use of multiple IM medication.

Based on record review and interview the facility failed to insure nursing staff followed medical staff orders for the care of 1 of 1 patient's identified.

On 12/6/2012 a review of patient (Pt) #1 Medical Record (MR) revealed the following: On 9/6/2012 the nursing staff documented Pt #2's admission wt was 88.4 kilo grams (Kg) (1 Kg equals 2.2 pounds). Pt #1 admission wt was 194.48 lbs. On 9/18/2012 pt #1 had a wt of 183 lbs. This is an 11.48 lb wt loss in 14 days.

Further MR review revealed the Registered Nurse Practitioner (RNP) had written an order dated 9/18/2012 as follows: "Push fluids, Re-weigh, dietary consult for wt (weight) loss". The corresponding progress note, dictated for the same date, revealed the following; "Weight: 183.0 which is 9 lbs (pounds) weight loss from last week, which tells me that he is not eating and drinking well". The order was noted by a staff RN however, no dietary consult was found. Continued MR review revealed, only the initial dietary evaluation, dated 9/6/2012..

On 12/6/2012 the RNP, staff #3, was interviewed and revealed the following: The RNP was familiar with Pt #1. The RNP also indicated she had evaluated him twice a week during his admission and treatment, while in the hospital. She further confirmed "I had reviewed his MR noting his weight loss". The RNP stated "I ordered a nutritional consult to address the suspected decrease in pt #1 appetite and subsequent weight loss".

A review of Pt #1 MR revealed no nursing documentation was identified indicating the Registered Dietician (RD) had been notified of the RNP order for a dietary consult. No consult re-assessing Pt #1 from the RD was found in Pt #1 MR. The suspected decreased appetite and the documented 11.48 lb wt loss on Pt #1 was not addressed in nursing documentation. A review, of the nursing staff documentation, did not reveal assessment nor intervention for the decrease in nutritional intake and wt loss for Pt #1.

Based on document review and interview the facility failed to insure the nursing staff identified and assessed the change of condition, which resulted in weight loss and contributed to skin breakdown for 1 of 1 patient's identified.

On 12/6/2012 the medical record (MR) for patient (Pt) #1 was reviewed and revealed the following documentation dated for the of 9/18, 9/19 and 9/20, 2012 indicated a change in the condition of Pt #1.
- On 9/6/2012 the nursing staff documented Pt #2's admission wt was 88.4 kilo grams (Kg) (1 Kg equals 2.2 pounds). Pt #1 admission wt was 194.48 lbs. On 9/18/2012, 12 days after admission, pt #1 had a wt of 183 lbs. Further MR review revealed the Registered Nurse Practitioner (RNP) had written an order dated 9/18/2012 as follows: "Push fluids, Re-weigh, dietary consult for wt (weight) loss". The corresponding progress note, dictated for the same date, revealed the following; "Weight: 183.0 which is 11.48 lbs (pounds) weight loss from last week, which tells me that he is not eating and drinking well".
- Review of the nursing documentation on the Braden Scale for predicting pressure sore risk from 95/2012 through 9/17/2012 documented a score of "23" very low risk. On 9/18/2012 the nurses documentation revealed a Braden Scale score of 18 which is a high risk for skin breakdown. There was no indication from nursing documentation that the change of condition for Pt #1 was identified. There was no nursing documentation the MD or RNP was notified of the change in the Braden scale score. The nursing staff failed to document an interventions related to pt #1 decrease in appetite and change in Braden Score.

Further review of Pt #1 dietary intake records revealed the Mental Health Technician, (MHT) recorded from 9/15/2012 to 10/2/2012 the following:
- Pt #1 ate 100% of any meal during the day, 4 times ( 9/15, 9/20, 9/22, and 9/23)
- Pt #1 ate less than 100% but greater than 50% of any meal during the day, 5 times (9/24, 9/26, 9/28, 9/28, and 10/2)
-Pt #1 ate 50% or less but greater than O% of any meal during the day, 25 times (9/15, 9/16/ x 2, 9/17 x 2, 9/19 x 2, 9/20, 9/21 x 2, 9/22, 9/24, 9/25 x 2, 9/26, 9/27 x 2, 9/29 x 3,9/30 x 2,10/1/ x 2, 10/2)
-Pt #1 ate 0% of any meal during the day, 17 times ( 9/15 x 2, 9/17, 9/18 x 3, 9/19, 9/21, 9/22, 9/23 x 2, 9/24, 9/26, 9/28, 9/30, 10/1,10/2).

On 9/25/2012 nursing staff documented Pt #1 weight as 182 with 10% meal intake. This is 12.48 lbs less than Pt #1 weighed on admission. The nursing staff failed to intervene. The nursing staff failed to notify the MD, RNP or the Registered Dietitian regarding Pt #1 poor appetite and 12.48 lb weighed loss. The nursing staff failed to identify this change in condition for Pt #.