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Based on record review, policy and procedure review and interviews, the Hospital failed to protect and promote the rights of 10 patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10), out a total sample of 15.

Findings include:

1) The Hospital failed to ensure that one patient, (Patient #1), was cared for in a safe setting and appropriately monitored after Patient #1 had an episode of hypotension (low blood pressure), a fall off the stretcher, was sedated for agitation and placed in 4 point restraints. Patient #1 was later found pulseless and breathless and resuscitation efforts were unsuccessful.

Please refer to A-0144 and A-0175

2) The Hospital failed to ensure that restraints used for nine patients (Patients #2, #3, #4, #5, #6, #7, #8, #9, and #10), out a total sample of 13 restrained patients, were the least restrictive and used only after other less restrictive interventions were attempted but ineffective.

Please refer to A-0164.

Based on record review, policy and procedure review and interviews, the Hospital failed to ensure care in a safe setting for one patient, (Patient #1) out of a total sample of 15 patients, in accordance with Hospital Policy.

Findings include:

The Emergency Department (ED) Nursing Record, dated 2/18/14 at 5:20 P.M. indicated that Patient #1 (Pt. #1) came to the ED for a suspected overdose but Pt. #1 refused to say which medications he/she ingested. The ED Nursing Record indicated that Pt. #1's vital signs were stable on admission with a heart rate (HR) of 98 (normal 60-100), respiratory rate (RR) of 20 (normal 16-20) and a blood pressure (BP) of 125/97 (normal 90-120 over 60-80).

The ED Physician Record indicated that Pt. #1's blood work and electrocardiogram (EKG-electrical activity of heart) were normal except for an elevated blood sugar of 218 (normal 60-110).

The ED Nursing Record, dated 2/18/14 at 10:35 P.M., indicated that Pt. #1's BP dropped to 67/36 with a HR of 57 with a follow-up BP of 85/49 and a HR of 59 recorded at the same time. The ED Nursing Record indicated that Pt. #1 was given intravenous (IV-into the vein) fluids and was placed in Trendelenburg (head lower than feet) to help increase blood pressure.

Review of the ED Nursing Record, dated 2/18/14 at 11:10 P.M., indicated that Pt. #1 was found out of bed and urinating on the floor.The ED Nursing Record indicated that Pt. #1 was assisted back to bed and one arm and one leg were restrained to prevent self-injury. The ED Nursing Record indicated that Pt. #1 became highly agitated and began to scratch his/her left arm so he/she was placed in 4-Point (all 4 limbs) restraints.

The Hospital Policy titled Restraints for Non-Psychiatric Units, last revised June of 2013, indicated that restraint used for violent, self-destructive behavior will require one-to-one observation and documentation every 15 minutes on the Restraint Flow Sheet.

The Restraint Flow Sheet for Management of Violent/Self-Destructive Behavior, dated 2/19/14 at 12:00 A.M., indicated that Patient #1 was placed on 1:1 observation and checked every 15 minutes for signs of injury, assessment of need for hydration (fluids), need for elimination, effect of restraint, and assessment of vital signs (at least once a shift).

The ED Nursing Record, dated 2/19/14 at 12:00 A.M., indicated that Pt. #1 was given Ativan (anti-anxiety medication) 2 milligrams (mg) IV for increased agitation.

The Surveyor interviewed ED Nurse #2 on 2/24/14 at 9:35 A.M. ED Nurse #2 was Pt.#1's caregiver on the 11:00 P.M. to 7:00 A.M. shift for 2/18/14. Nurse #2 said that she received report from ED Nurse #1 at 11:00 P.M.on 2/18/14 and was told Pt. #1's blood pressure had been low. ED Nurse #2 said she told ED Technician #1 to get a set of vital signs on Patient #1 after the change of shift report.

The Surveyor interviewed ED Technician #1 on 2/27/14 at 8:25 A.M. ED Technician #1 said that she did not remember being told to get a set of vital signs on Pt. #1.

ED Policy N-14.2, Nursing Assessment and Reassessment of the Patient, last revised June of 2011, indicated that the nurse assesses the patient's vital signs based on condition, response to medication, treatments or other interventions. The Policy indicated that all patients with abnormal vital signs will have repeat vital signs at least once prior to discharge from the ED and all patients given sedative medication will have vital signs reassessed.

The Nursing Drug Handbook, 2014 Edition 34, indicated that Ativan may cause hypotension (low BP) and have a sedating effect.

The ED Nursing Record, dated 2/19/14 at 3:00 A.M., indicated that Pt. #1 appeared to be less restless and one hand was removed from restraint.

The ED Nursing Record, dated 2/19/14 at 4:00 A.M., indicated that Pt. #1 was observed to be sleeping and his/her respirations were regular.

ED Nurse #2 said that, at 4:20 A.M. on 2/19/14, she realized that no vital signs had been taken on Pt. #1 since she had come on duty. ED Nurse #2 said that she went into Pt. #1's room at 4:20 A.M. and Pt. #1 was pulseless and breathless. Resuscitation efforts were unsuccessful and Pt. #1 was pronounced dead at 4:46 A.M.

There was no evidence on the ED Nursing Flow Sheet that a blood pressure had been taken since 10:35 P.M. on 2/18/14 when Pt. #1's blood pressure was 85/49.

An ED Addendum Note written by ED RN #1, dated 2/19/14 at 4:30 P.M., referring to Pt. #1's care on 2/18/14 at 7:00 P.M., indicated that Pt. #1 was found prone on the floor and was assisted back to the stretcher.

The Physician Order Sheet, dated 2/18/14 at 7:00 P.M, indicated that Pt. #1 was to be placed on a cardiac monitor and sent for a Cat Scan (x-ray that provides more detailed imaging) of the head to rule out a head injury.

An ED Addendum Note by ED RN #1, dated 2/19/14 at 4:30 P.M., referring to Pt. #1's care on 2/18/14 at 9:19 P.M., indicated that Pt. #1 ripped off the cardiac leads and was found standing in the hallway. The ED Addendum Note indicated that Pt. #1 was moved closer to the nursing station for Security to watch.

The ED Nursing Record and ED Addendum Note did not indicate that Pt.#1 was placed back on a cardiac monitor.

The Physician Order Sheet did not indicate that the cardiac monitor was discontinued.

Based on record review, policy and procedure review and interviews, the Hospital failed to ensure that restraints used for 9 patients, (Pt.'s #2, #3, #4, #5, #6, #7, #8, #9, and #10) out a total sample of 13 restrained patients, were the least restrictive and used only after other less restrictive interventions were attempted but ineffective.

Findings include:

The Hospital Policy titled Restraints for Non-Psychiatric Units, last revised in June of 2013, indicated that restraints will only be used after the patient has been assessed and alternative interventions have been deemed ineffective and that staff should attempt to use the least restrictive form of restraint that will protect the physical safety of the patient.

1) The ED Nursing Record, dated 10/13/12 at 6:00 P.M., indicated that Patient #2 (Pt. #2) came to the Hospital Emergency Department (ED) for a suspected overdose. The ED Nursing Record indicated that Pt. #2 was uncooperative and rude.

Review of the ED Physician Record for Pt. #2, dated 10/12/13 at 6:20 P.M., indicated that Pt.#2 was angry and yelling.

Review of the ED Physician Restraint Order Form, dated 10/12/13 at 7:30 P.M., indicated that, for Pt. #2, alternatives to restraint were attempted and were ineffective i.e. modification of environment, explanation/education, comfort measures (Pt. #2 reported 10/10 hip pain-numeric pain scale where 0 is no pain and 10 is the worst), distraction/sensory interventions and a medication evaluation/as needed medication offered.

Review of the ED Nursing Notes indicated that Pt.#2 was placed in 4-point restraint and was administered Zyprexa (medication for agitation) 10 milligrams (mg) intramuscularly (IM), on 10/12/13 at 8:30 P.M., a simultaneous chemical and physical restraint.

Review of the ED Nursing Notes, dated 10/12/13 from 6:00 P.M (time of triage-assessment of patient upon arrival) to 8:30 P.M. (time of restraint), did not indicate that any of the alternatives interventions to physical restraint were attempted nor was pain medication ordered or offered.

2) The ED Nursing Record, dated 10/18/13 at 3:44 A.M., indicated Patient #3 (Pt. #3) came to the Hospital ED for abdominal pain and vomiting. The ED Nursing Record indicated that Pt. #3 was agitated and trying to climb off the stretcher.

Review of the ED Physician Notes, dated 10/18/13 at 4:00 A.M, indicated that Pt. #3 was exhibiting violent behavior.

The ED Nursing Record indicated that, on 10/18/14 at 4:00 A.M., Pt.#3 was administered Ativan (anti-anxiety medication) 2mg intravenously (IV), Haldol (for agitation) 10mg IM with Cogentin (lessens side effects of Haldol) 1mg IM at 4:05 A.M. and 4-point restraint application at 4:10 A.M., a simultaneous chemical and physical restraint.

Review of the ED Physician Restraint Order Form, dated 10/18/13 at 4:10 A.M. indicated that, for Pt. #3, alternatives to restraint were attempted and were ineffective i.e. modification of environment, companionship/supervision, explanation/education, comfort measures (Pt. #3 reported 10/10 abdominal pain), distraction/sensory interventions and a medication evaluation/as needed medication offered.

Review of the ED Nursing Notes dated 10/18/13 from 3:49 A.M. (time of triage) to 4:10 A.M. (application of restraints) did not indicate that any of the Physician's documented alternative interventions to physical restraint were attempted nor was pain medication ordered or offered.

3) The ED Nursing Record, dated 10/21/13 at 4:40 P.M., indicated that Patient #4 (Pt. #4) came to the Hospital ED for a suspected overdose.

The ED Nursing Record, dated 10/21/13 at 5:15 P.M., indicated that Pt. #4 was a "flight risk" so he/she was made a 1:1 observation and 2-point restraints (1 arm and 1 leg) were applied. The ED Nursing Record indicated that Pt. #4 was calm and cooperative and did not indicate that Pt. #4 was violent and/or attempting to hurt self or others.

Review of the ED Physician Restraint Order Form, dated 10/21/13 at 5:15 P.M., indicated that, for Pt. #4, no alternatives to restraint were attempted.

The Restraint Flow Sheet for Management of Violent/Self-Destructive Behavior, dated 10/21/12 at 9:15 P.M., indicated that Pt. #4's restraints were removed.

4) The ED Nursing Record, dated 11/22/13 at 5:20 P.M., indicated that Patient #5 (Pt. #5) came to the Hospital ED for anxiety and "flight of thoughts". The ED Nursing Record indicated that Pt. #5 was "uncooperative and fighting with police" and was placed in 4-point restraint in triage.

Review of the ED Physician Restraint Order Form, dated 11/22/13 at 5:20 P.M., indicated that, for Pt. #5, alternatives to restraint were attempted and were ineffective i.e. modification of environment, companionship/supervision, explanation/education, comfort measures, and distraction/sensory interventions.

Review of the ED Nursing Notes dated 11/22/13 at 5:20 P.M. (time of triage) indicated that the application of restraints was occurring simultaneously with the Physician's documentation that all alternatives to restraint were attempted but unsuccessful. The ED Nursing Notes did not indicate that these alternatives to restraint were attempted.

5) The ED Nursing Record, dated 11/30/13 at 3:56 P.M. indicated that Patient #6 (Pt. #6) came to the Hospital ED for suicidal ideation and alcohol intoxication.

The ED Nursing Record, dated 11/30/13 at 5:20 P.M., indicated that Pt. #6 was agitated and aggressive toward security and nursing staff and was placed in 4 point restraint.

Review of the ED Physician Restraint Order Form, dated 11/30/13 at 5:30 P.M., indicated that, for Pt. #6, alternatives to restraint were attempted and were ineffective i.e. modification of environment, companionship/supervision, explanation/education, comfort measures, and distraction/sensory interventions and medication evaluation/as needed medication offered.

Review of the ED Nursing Notes dated 11/30/13 from 3:56 P .M. (time of triage) to 5:35 P.M. (application of restraints) did not indicate that any of the Physician's documented alternative interventions to physical restraint were attempted.

6) The ED Nursing Record, dated 12/12/13 at 4:10 P.M. indicated that Patient #7 (Pt. #7) came to the Hospital ED for alcohol withdrawal. The ED Nursing Record indicated that Pt. #7 was "aggressive and impulsive" and was placed in 4 point restraint at 4:15 P.M. and was administered Ativan 2mg IV, Haldol 5mg IM and Cogentin 1mg IM at 4:18 P.M., a simultaneous chemical and physical restraint.

Review of the ED Physician Restraint Order Form, dated 12/12/13 at 4:15 P.M., indicated that, for Pt. #7, alternatives to restraint were attempted and were ineffective i.e. modification of environment, companionship/supervision, explanation/education, comfort measures, and medication evaluation/as needed medication offered.

Review of the ED Nursing Notes dated 12/12/13 at 4:10 P.M.(time of triage) to 4:15 P.M. (application of restraints) indicated that the application of restraints was occurring simultaneously with the Physician's documentation that all alternatives to restraint were attempted but unsuccessful. The ED Nursing Notes did not indicate that these alternatives to restraint were attempted.

7) The ED Nursing Record, dated 1/8/14 at 9:15 P.M., indicated that Patient #8 (Pt. #8), a pediatric patient) came to the Hospital ED for a psychiatric evaluation.

The ED Nursing Record, dated 1/8/14 at 9:27 P.M., indicated that Pt. #8 kicked a nurse and was spitting at staff.

The ED Nursing Record, dated 1/8/14 at 9:40 P.M., indicated that Pt. #8 was administered Ativan 1mg IV, Haldol 5mg IM and Cogentin 1mg IM and was placed in 4 point restraint, a simultaneous chemical and physical restraint.

Review of the ED Physician Restraint Order Form, dated 1/8/14 at 9:50 P.M., indicated that, for Pt. #8, alternatives to restraint were attempted and were ineffective i.e. modification of environment, companionship/supervision, explanation/education, comfort measures, and medication evaluation/as needed medication offered.

Review of the ED Nursing Notes dated 1/8/14 at 9:15 P.M. (time of triage) to 9:40 P.M. indicated that the application of restraints was occurring simultaneously with the Physician's documentation that all alternatives to restraint were attempted but unsuccessful. The ED Nursing Notes did not indicate that these alternatives to restraint were attempted.

8) The ED Nursing Record, dated 1/13/14 at 11:00 P.M., indicated that Patient #9 (Pt. #9) came to the Hospital ED for a psychiatric evaluation. The ED Nursing Record indicated that Pt. #9 was crying and screaming.

The Restraint Flow Sheet for Management of Violent/Self-Destructive Behavior, dated 1/13/14 at 11:00 P.M., indicated that Pt. #9 was placed in 4-point restraint upon arrival to the ED with no corresponding documentation regarding Pt. #9's behavior or reason for restraint.

Review of the ED Physician Restraint Order Form, dated 1/13/14 at 11:00 P.M., did not indicate that any alternatives to restraint were attempted except "explanation/education".

9) The ED Nursing Record, dated 1/27/14 at 8:50 P.M., indicated that Patient #10 (Pt. #10) came to the Hospital ED for a psychiatric evaluation.

The Restraint Flow Sheet for Management of Violent/Self-Destructive Behavior, dated 1/27/14 at 9:00 P.M., indicated that Pt. #10 was placed in 2-point (1 arm & 1 leg) restraints with no corresponding documentation regarding Pt. #10's behavior or reason for restraint.

Chemical restraint (injection of a drug to control behavior) is considered the most restrictive since once given, the drug cannot be withdrawn and may have long term adverse affects such as tremors. Physical restraints such as wrist or leg restraints can be removed immediately with little or no lingering side effects.



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Based on record review, interviews and review of the Hospital's Restraint Policy, the Hospital failed to ensure that one patient, Patient #1 (Pt. #1), out of a total sample of 13 restrained patients, was appropriately monitored while in restraints.

Findings include:

The Hospital Policy titled Restraints for Non-Psychiatric Units, last revised in June of 2013, indicated that the Registered Nurse will obtain and document vital signs as appropriate for diagnosis but at least once each shift while the patient is in restraints and as appropriate to the patient's condition.

The Emergency Department (ED) Nursing Record, dated 2/18/14 at 5:20 P.M. indicated that Pt. #1 came to the ED for a suspected overdose. The ED Nursing Record indicated that Pt. #1's vital signs were stable on admission with a heart rate (HR) of 98 (normal 60-100), respiratory rate (RR) of 20 (normal 16-20) and a blood pressure (BP) of 125/97 (normal 90-120 over 60-80).

The ED Nursing Record, dated 2/18/14 at 10:35 P.M., indicated that Pt. #1's BP dropped to 67/36 with a HR of 57 with a follow-up BP of 85/49 and a HR of 59 recorded at the same time. The ED Nursing Record indicated that Pt. #1 was given intravenous fluids and was placed in Trendelenburg (head lower than feet) to help increase blood pressure.

The ED Nursing Record, dated 2/18/14 at 11:10 P.M., indicated that Pt. #1 was found out of bed and urinating on the floor.The ED Nursing Record indicated that Pt. #1 was assisted back to bed and one arm and one leg were restrained. The ED Nursing Record indicated that Pt. #1 became highly agitated and began to scratch his/her left arm so he/she was placed in 4-Point (all 4 limbs) restraints.

The Surveyor interviewed ED Nurse #2 on 2/24/14 at 9:35 A.M. ED Nurse #2 was Pt.#1's caregiver on the 11:00 P.M. to 7:00 A.M. shift for 2/18/14. Nurse #2 said that she received report from ED Nurse #1 RN at 11:00 P.M.on 2/18/14 and was told Pt. #1's blood pressure had been low. ED Nurse #2 said she told ED Technician #1 to get a set of vital signs on Pt. #1 after the change of shift report.

The Surveyor interviewed ED Technician #1 on 2/27/14 at 8:25 A.M. ED Technician #1 said that she did not remember being told to get a set of vital signs on Pt. #1.

The ED Nursing Record, dated 2/19/14 at 12:00 A.M., indicated that Pt. #1 was given Ativan (anti-anxiety medication) 2 milligrams (mg) intravenously (IV-into the vein) for increased agitation. The ED Nursing Record did not indicate that a blood pressure was taken prior to the administration of Ativan.

ED Policy N-14.2, Nursing Assessment and Reassessment of the Patient, last revised in June of 2011, indicated that the nurse assesses the patient's vital signs based on condition, response to medication, treatments or other interventions. The Policy indicated that all patients with abnormal vital signs will have repeat vital signs at least once prior to discharge from the ED and all patients given sedative medication will have vital signs reassessed.

The Nursing Drug Handbook, 2014 Edition 34, indicated that Ativan may cause hypotension (low BP) and have a sedating effect.

The Restraint Flow Sheet for Management of Violent/Self-Destructive Behavior indicated that Pt. #1 was on 1:1 observation and was checked every 15 minutes.

The ED Nursing Record, dated 2/19/14 at 3:00 A.M., indicated that Pt. #1 appeared to be less restless and one hand was removed from restraint.

The ED Nursing Record, dated 2/19/14 at 4:00 A.M., indicated that Patient #1 was observed to be sleeping and his/her respirations were regular.

ED Nurse #2 said that, at 4:20 A.M on 2/19/14, she realized that no vital signs had been taken on Patient #1 since she had come on duty. ED Nurse #2 said that she went into Pt.#1's room at 4:20 A.M. and Pt. #1 was pulseless and breathless. Resuscitation efforts were unsuccessful and Pt. #1 was pronounced dead at 4:46 A.M.

Review of the ED Nursing Flow Sheet did not indicate that a blood pressure was obtained after 10:35 P.M. on 2/18/14 when Pt. #1's blood pressure was 85/49.

Based on record review, policy and procedure review and interviews, the Condition of Nursing Services is not met as evidenced by: a) the failure of nursing staff to appropriately assess one patient, Patient #1, in a total sample of 15 patients, on an ongoing basis in accordance with accepted standards of nursing practice; b) the failure of nursing staff to ensure that Patient #1's plan of care was reviewed, revised and implemented according to Hospital Policy after Patient #1 sustained a fall and c) the failure of nursing staff to ensure that verbal orders were obtained, documented and verified for 7 ((Pt. #1, Pt. #2, Pt. #5, Pt. #6, Pt. #7, Pt. #8, and Pt. #9) of 15 sampled patients, in accordance with Hospital Policy.

Findings include:

1) Nursing Staff failed to ensure that Patient #1 was appropriately assessed on an ongoing basis after Patient #1 had an episode of hypotension (low blood pressure), sustained a fall, was sedated and placed in 4 point restraints (both arms and both legs) and was eventually found pulseless and breathless. The patient was unable to be resuscitated.

Please refer to A-0395

2) Nursing Staff failed to ensure that Patient #1's plan of care was kept current by ongoing assessment of Patient #1's needs after Patient #1 was found prone on the floor after a fall off of his/her stretcher and sustaining a possible head injury. Staff failed to monitor Patient #1 for neurological vital sign (assessment of a patient's level of consciousness in conjunction with monitoring of pulse, respiration and blood pressure) changes in accordance with Hospital Policy regarding patient assessment after a fall.

Please refer to A-0396

3) Nursing Staff failed to ensure that verbal orders for 7 patients, (Pt. #1, Pt. #2, Pt. #5, Pt. #6, Pt. #7, Pt. #8, and Pt. #9), out of a total sample of 15 patients, were obtained, documented and verified in accordance with Hospital Policy.

Please refer to A-0407

Based on record review, interviews and review of the Hospital's Nursing Assessment and Reassessment of the Patient in the Emergency Department Policy, the Hospital failed to ensure that one patient, Patient #1 (Pt. #1), out of a total sample of 15 patients, was appropriately assessed on an ongoing basis, in accordance with accepted standards of nursing practice and hospital policy.

Findings include:

The Emergency Department (ED) Nursing Record, dated 2/18/14 at 5:20 P.M. indicated that Pt. #1 (Pt. #1) came to the ED for a suspected overdose. The ED Nursing Record indicated that Pt. #1's vital signs were stable on admission with a heart rate (HR) of 98 (normal 60-100), respiratory rate of 20 (normal 16-20) and a blood pressure (BP) of 125/97 (normal 90-120 over 60-80).

The ED Nursing Record, dated 2/18/14 at 10:35 P.M., indicated that Pt. #1's BP dropped to 67/36 with a HR of 57 with a follow-up BP of 85/49 and a HR of 59 recorded at the same time. The ED Nursing Record indicated that Patient #1 was given intravenous fluids and was placed in Trendelenburg (head lower than feet) to help increase blood pressure.

The Surveyor interviewed ED Nurse #2 on 2/24/14 at 9:35 A.M. ED Nurse #2 was Pt.#1's caregiver on the 11:00 P.M. to 7:00 A.M. shift for 2/18/14. Nurse #2 said that she received report from ED Nurse #1 RN at 11:00 P.M.on 2/18/14 and was told Pt. #1's blood pressure had been low. ED Nurse #2 said she told ED Technician #1 to get a set of vital signs on Pt. #1 after the change of shift report.

The Surveyor interviewed ED Technician #1 on 2/27/14 at 8:25 A.M. ED Technician #1 said that she did not remember being told to get a set of vital signs on Pt. #1.

The ED Nursing Record, dated 2/19/14 at 12:00 A.M., indicated that Pt. #1 was given Ativan (anti-anxiety medication) 2 milligrams (mg) intravenously (IV-into the vein) for increased agitation.

ED Policy N-14.2, Nursing Assessment and Reassessment of the Patient, last revised in June of 2011, indicated that the nurse assesses the patient's vital signs based on condition, response to medication, treatments or other interventions. The Policy indicated that all patients with abnormal vital signs will have repeat vital signs at least once prior to discharge from the ED and all patients given sedative medication will have vital signs reassessed.

The Nursing Drug Handbook, 2014, Edition 34, indicated that Ativan may cause hypotension (low BP) and have a sedating effect.

The ED Nursing Record, dated 2/19/14 at 4:00 A.M., indicated that Pt. #1 was observed to be sleeping and his/her respirations were regular.

ED Nurse #2 said that, at 4:20 A.M. on 2/19/14, she realized that no vital signs had been taken on Pt. #1 since she had come on duty. ED Nurse #2 said that she went into Pt. #1's room at 4:20 A.M. and Pt. #1 was pulseless and breathless. Resuscitation efforts were unsuccessful and Pt. #1 was pronounced dead at 4:46 A.M.

Review of the ED Nursing Flow Sheet did not indicate that a blood pressure was obtained after 10:35 P.M. on 2/18/14 when Pt. #1's blood pressure was 85/49.

Based on record review, policy/procedure review and interviews, the Hospital failed to ensure that one patient's plan of care, Patient #1 (Pt. #1), was reviewed, revised and implemented after Pt. #1 was found prone on the floor after falling off his/her stretcher and sustaining a possible head injury.

The Emergency Department (ED) Nursing Record, dated 2/18/14 at 5:20 P.M. indicated that Patient #1 (Pt. #1) came to the ED for a suspected overdose. The ED Nursing Record indicated that Pt. #1's vital signs were stable on admission with a heart rate (HR) of 98 (normal 60-100), respiratory rate (RR) of 20 (normal 16-20) and a blood pressure (BP) of 125/97 (normal 90-120 over 60-80).

The ED Nursing Record, dated 2/18/14 at 10:35 P.M., indicated that Pt. #1's BP dropped to 67/36 with a HR of 57 with a follow-up BP of 85/49 and a HR of 59 recorded at the same time. The ED Nursing Record indicated that Pt. #1 was given intravenous (IV-into the vein) fluids and was placed in Trendelenburg (head lower than feet) to help increase blood pressure.

An ED Addendum Note written by ED RN #1, dated 2/19/14 at 4:30 P.M., referring to Pt. #1's care on 2/18/14 at 7:00 P.M., indicated that Pt. #1 was found prone on the floor and was assisted back to the stretcher.

The Physician Order Sheet, dated 2/18/14 at 7:00 P.M, indicated that the Physician ordered Pt. #1 to be placed on a cardiac monitor and sent for a Computerized Tomography (CT) Scan (x-ray that provides more detailed imaging) of his/her head to rule out a head injury.

The Hospital Policy titled Fall Prevention, last revised October of 2012, indicated that should a patient sustain a head injury of any type from a fall, the Registered Nurse (RN) will complete the Neurological Assessment (an assessment of a patient's level of consciousness, vital signs and pupillary response to light) Sheet and monitor the patient's vital signs every 15 minutes for 1 hour, every 30 minutes for 2 hours, and every hour for 4 hours.

An ED Addendum Note by ED RN #1, dated 2/19/14 at 4:30 P.M., referring to Pt. #1's care on 2/18/14 at 9:19 P.M., indicated that Pt. #1 ripped off the cardiac leads and was found standing in the hallway. The ED Addendum Note indicated that Pt. #1 was moved closer to the nursing station for Security to watch.

The ED Nursing Record and ED Addendum Note did not indicate that Pt.#1 was placed back on a cardiac monitor.

The ED Nursing Record did not indicate any check of Pt. #1's vital signs after his/her fall.

Pt. #1's ED Record did not contain a Neurological Assessment Sheet.

The Physician Order Sheet did not indicate that the cardiac monitor was discontinued.

Based on record review, policy/procedure review, and interviews, the Hospital failed to ensure that verbal orders for 7 patients, (Pt. #1, Pt. #2, Pt. #5, Pt. #6, Pt. #7, Pt. #8, and Pt. #9), out of a total sample of 15 patients, were in accordance with Hospital Policy.

Findings include:

The Hospital Policy titled, Doctors' Orders, last reviewed July 2012, indicated that designated personnel who receive a verbal order will document the following in the patient's chart: a) specifics of the order, b) date and time the verbal order was received, c) name of the doctor who gave the order, d) the registered nurse's first initial, last name and professional designation and e) the complete order written in the patient's chart, verified and read back.

1. The ED Nursing Record, dated 2/19/14 at 12:00 A.M., indicated that Patient #1 (Pt. #1) was given Ativan (anti-anxiety medication) 2 milligrams (mg), intravenously (IV-into the vein), for increased agitation.

The Surveyor interviewed ED Nurse #2 on 2/24/14 at 9:35 A.M. ED Nurse #2 said that the order for Ativan was a verbal order given by ED Physician #2.

The Surveyor interviewed ED Physician #2 on 2/25/14 at 8:00 A.M. ED Physician #2 said he did not remember giving the order for Ativan.

Review of the ED Physician's Orders for Patient #1 did not indicate a written order for Ativan, by Physician #2 or a verbal order, written and verified by ED Nurse #2.

2. The Physician Orders for Patient #2, dated 10/13/13 at 4:30 A.M., indicated that the nurse took a telephone order for an Albuterol updraft nebulizer (breathing treatment) which was not verified and read back nor authenticated by the ordering physician.

The Physician Orders for Patient #2, dated 10/13/13/ at 3:35 P.M., indicated that the nurse took a verbal order for Zyprexa (anti-anxiety medication) 10 mg, by mouth, from the physician which was not verified and read back nor authenticated by the ordering physician.

3. The Physician Orders for Patient #5, dated 11/22/13 at 10:21 P.M., indicated that the nurse took a verbal order for Ativan (anti-anxiety medication) 2 mg, by mouth, which was not verified and read back.

4. The Physician Orders for Patient #6, dated 12/1/13 at 10:25 A.M., indicated that the nurse took a verbal order for a Nicotine Patch (to decrease craving for cigarettes) 21 mg, which was not verified and read back.

The Physician Orders for Patient #6, dated 12/1/13 at 1:10 P.M., indicated that the nurse took a verbal order for Amlodipine (lowers blood pressure), 10 mg, by mouth, Atorvastatin(lowers cholesterol), 80 mg, by mouth and Aspirin 81 mg, by mouth, that was not verified and read back nor authenticated by the ordering physician.

5. The Physician Orders for Patient #7, dated 12/13/13 at 10:17 A.M., indicated that the nurse took a verbal order for a Nicotine Patch 21 mg, that was not verified and read back.

6. The Physician Orders for Patient #8, dated 1/9/14 at 7:30 A.M., indicated that the nurse took a verbal order for Abilify (antipsychotic) 10 mg, by mouth, Buspirone (anti-anxiety) 10 mg, by mouth and Clonidine (antihypertensive) 0.2 mg, by mouth that was not verified and read back.

The Physician Orders for Patient #8, dated 1/9/14 at 7:59 A.M., indicated that the nurse took a verbal order for Ativan 1 mg by mouth that was not verified and read back.

7. The Physician Orders for Patient #9, dated 1/13/14 at 11:10 P.M., indicated that the nurse took a verbal order for Haldol (for agitation) 5 mg intramuscularly (IM-into the muscle), Cogentin (lessens side effects of Haldol) 1 mg IM, and Ativan 2 mg IM that was not verified and read back.