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Based on interviews and record review, the facility failed to ensure nursing staff notified a provider when a patient or patient's family relayed concerns with medication in 1 of 8 medical records reviewed for patients in the inpatient behavioral health unit (Patient #5).

Findings include:

Facility policies:

The Documentation- Nursing policy read, documentation needs to be timely and accurately reflect the patients' needs for care. The practice of nursing includes the documentation of clinical information and nursing care into the patient's medical record. The standards of clinical practice as described by the American Nurses Association include the following: documents diagnoses and issues in a manner that facilitates determination of the plan; documents implementation and any modifications, including changes or omissions of the identified plan; documents coordination of care. The purpose of documenting clinical information in the patient's medical record include: communicate, coordinate and collaborate with the health care team, including the patient and family; communicate patients' clinical information, including the patient's medical history, between care givers to assure continuity of care. Interventions, treatments and nursing are provided are documented when complete.

1. The facility failed to ensure nursing staff notified the physician regarding patient's chronic pain medication when Patient #5 and her mother had concerns after being admitted to the inpatient behavioral health unit.

a. Patient #5's medical record was reviewed. Review of the history and physical (H&P) completed on 9/18/19 at 2:06 p.m., read Patient #5 was in the intensive care unit (ICU) due to an overdose on multiple medications. It was documented Patient #5 had a history of UC (ulcerative colitis, a chronic inflammatory bowel disease) and chronic abdominal pain with opioid dependence. The assessment and plan documented by the physician stated, resume Suboxone (a narcotic used to treat pain which has a high risk for dependence) tonight. A physician order was entered 9/18/19 at 1:05 p.m. for Suboxone 8 mg/2mg 0.5 tab to be given twice daily.

On 9/19/19 at 4:43 p.m., Patient #5 was admitted to the inpatient behavioral health unit from the hospital ICU. Registered Nurse (RN) #3, who was responsible for the patient's care on 9/19/19, entered a note at 6:07 p.m., which read, chronic pain issues and Patient #5 was documented by the RN to state "I have chronic pain in my abdomen because of my brain rewiring."

RN #3 entered an additional note at 9:13 p.m. which read, Patient #5's mother called the unit and spoke to the RN. The RN documented Patient #5's mother continued to insist her daughter be given Suboxone and expressed concerned Patient #5 was going to experience severe pain and accused providers of making Patient #5 go "cold turkey". Patient #5's mother continued repeating over and over, "She is going cold turkey".

Review of Patient #5's medical record revealed no evidence RN #3 notified the provider of the concerns regarding the discontinuation of the patient's chronic pain medication or opiate withdrawal expressed by Patient #5's mother.

b. On 1/6/20 at 12:10 p.m. an interview was conducted with RN #1. RN #1 stated medications and physician orders were reviewed as part of the nurse's initial assessment of a newly admitted patient. RN#1 stated if there were missing medications or orders for a new patient, or if the nurse had questions regarding a medical problem, the nurse would contact the patient's provider.

c. On 1/8/20 at 9:34 a.m. an interview was conducted with RN #2. RN #2 stated when the nurse completed an admission assessment for a newly admitted patient on the inpatient behavioral health unit, the nurse reviewed orders for medications and medical needs with the patient. RN #2 stated she would notify a provider for any reason a patient wanted to speak with a doctor, including a question about medication. She stated if a newly admitted patient noted anything incorrect during the review of medications, she would raise this concern immediately with the provider to get it changed.

RN #2 stated for questions regarding a pain medication, she would first notify the hospitalist. She stated she did not believe a pain medication like Suboxone could be discontinued abruptly, and if she noticed a medication like Suboxone was discontinued without evidence of a clinical reason she would communicate this to a provider. RN #2 stated this communication should occur as soon as the patient was situated on the unit, ideally within 30 minutes and absolutely within the same shift. RN #2 stated communication with providers was important for continuity of care, and stated as a healthcare provider it would be her responsibility to investigate an issue because she could not know whether a medication was missed or if the doctor made a decision to discontinue a medication but did not document it.

RN #2 stated the nurse would usually write a nursing note to document communication with a provider. She stated communication with a provider should be documented in the medical record because it was relevant to the patient's care and she would want it noted and passed on to other caregivers.

d. On 1/8/20 at 2:00 p.m., an interview was conducted with RN #3. RN #3 stated nurse communication with a provider was variable depending on the patient's needs or circumstances. She stated communication with a provider would occur to update the physician on the patient's condition, clarify medication or admission orders, and address any questions. She stated medication questions or concerns would be a reason to contact a provider.

RN #3 stated communication with a provider should be documented in the chart, and stated she needed to get better at completing this documentation. She stated it was an expectation for nurses to document communication and involvement of the physician in a patient's care and stated it was important for overall patient care to do so.

RN #3 reviewed Patient #5's medical record. She stated she recalled the patient and her family member were concerned about Suboxone.

On review of Patient #5's medical record, RN #3 was unable to locate any evidence of communication between herself and the provider regarding the patient's and family member's concerns with pain medication.

RN #3 stated it was vital to document in this situation because if something was not documented, it did not happen.

e. On 1/8/20 at 11:06 a.m. an interview was conducted with the Nurse Manager of the Inpatient Behavioral Health Unit (Manager #4). Manager #4 stated a physician should be notified any time something was out of the ordinary and the nurse felt it required either medication or a behavioral health intervention. She stated a nurse should always err on the side of calling the physician because the nurse was an advocate for the patient and if the patient had a need the nurse should inform the provider. She stated she always wanted nurses to call the provider with any concerns.

Manager #4 stated when a nurse communicated with a physician there must be documentation in the medical record. She stated in Meditech (the Electronic Health Record system in use at the facility during the time of Patient #5's hospitalization) there was an intervention called "Provider Notified" where phone calls to the provider and the outcome were documented. She stated although not all nurses were good at completing this documentation, it was absolutely the expectation for the documentation be completed in the record if there was communication with the psychiatrist or the hospitalist. She stated the other option was to write a nursing note.

Manager #4 reviewed Patient #5's medical record. She stated she did not see RN #3 documented a "Provider Notified" intervention on 9/19/19, nor did she see evidence in RN #3's nursing notes for the same date whether the physician was contacted. She stated her expectation would be for RN #3 to contact the psychiatrist based on new information and concerns regarding pain medication expressed by Patient #5 and her family member. Manager #4 stated she would furthermore expect to see a note or intervention reflecting this communication with the physician.

Manager #4 stated the medical chart reflected the provider was not notified of the concerns Patient #5 and her family member expressed regarding pain medication.