HospitalInspections.org

Based on observation, interview and document review, the hospital failed to maintain medical records that contained accurate and complete information regarding the assessment and active treatment for 8 of 8 active sample patients (C3, C4, C10, C14, D3, D7, E4 and E6) and 14 non-sample patients chosen for medication review (C1, C2, C5, C6, C8, C9, C11, C13, C15, C16, C17, C18, D2 and D4). Specifically, the facility failed to:

I. Develop and document comprehensive multidisciplinary treatment plans to address presenting problems for 3 of 8 active sample patients (C3, E4 and E6) and one of 14 non-sample patients (C13) to direct staff in the care of these patients. This failure results in fragmented treatment, lacking orientation to individualized patient goals. (Refer to B118.)

II. Develop master treatment plans that identified clearly delineated physician, nursing and social work interventions to address the specific treatment needs of 8 of 8 active sample patients (C3, C4, C10, C14, D3, D7, E4 and E6). Interventions were chosen from a preprinted list, the majority being routine, generic discipline functions, without information added to individualize the plans based on patient needs. This failure results in master treatment plans that were similar, or identical, and which fail to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

III. Ensure that patients were able to participate in active programming on Unit C. Patients were over- medicated through the use of PRN (as needed) sedating medications for one of four active sample patients (C3), and one of 14 non-sample patients chosen for review of medication usage (C13) on Unit C. Both patients complained that they were unable to participate in unit activities secondary to over sedation. This failure may unnecessarily prolong a patient's hospitalization. (Refer to B125, Part I.)

IV. Ensure that physician orders provided adequate guidance to nursing staff on the administration of antipsychotic, antianxiety and/or pain medications for 4 of 8 active sample patients (C3, C4, C10 and C14) and for 9 of 14 non sample patients (C1, C2, C5, C6, C8, C13, C15, C16 and C17) added for medication order review. For these patients, physician orders were written on a PRN (as necessary) basis for "anxiety", "psychosis" or "EPS" (extrapyramidal symptoms) with no specification of the delivery method. Nurses could choose to administer the same dose of medications by "IM" (intramuscular injection) or "p.o." (orally), and failed to document the rationale for the route of administration of the medications. Additionally, 1 of 8 active sample patients (C10) and 2 of 14 non-sample patients (C9 and D4) had PRN orders for at least two different medications for identical indications, without specific guidance to nursing as to which medication to use. These failures place the nursing staff in a situation that requires them to function beyond the scope of nursing practice. Ambiguous physician orders can result in serious complications from improperly administered PRN medications. (Refer to B125 Part II.)

V. Ensure that when medications were used which decreased patient participation in treatment they were recognized as chemical restraint, for one of eight active sample patients (C3) and one of fourteen non-sample patients (C13) reviewed for medication usage. Nursing staff administered medications that resulted in the patients missing group therapies and/or sleeping during groups. Nursing notes and interviews indicated these medications were being used to control behaviors. Nursing staff failed to recognize these events as chemical restraint and did not complete seclusion/restraint documentation for the patients. This failure violates a patient's right to be free of restrictive measures without justification. (refer to B125 Part III.)




18051

Based on record review and interview, it was determined that the facility failed to ensure that physicians performed and documented an estimate of memory functioning in 5 of 8 psychiatric evaluations (C3, C4, C14, D3 and D7). The failure to document specific testing compromises the identification of pathology which may be pertinent to the current mental illness and compromises future comparative re-examination to assess patient's response to treatment interventions.

Findings include:

A. Record Review

1. Patient C3: In the Mental Status Section of the Admission Psychiatric Evaluation written 8/29/11, the following was noted for "Memory": "Patient unable to respond to testing." Review of daily Psychiatric Progress Notes after the date of admission failed to identify any memory testing being completed by the physician even though the preprinted form for physician progress notes included a section for memory testing under the mental status examination section of the note.

2. Patient C4: In the Mental Status section of the Admission Psychiatric Evaluation written 8/20/11, the following was noted for "Memory": "Unable to assess." Review of daily Psychiatric Progress Notes after the date of admission failed to identify any memory testing being completed by the physician even though the preprinted form for physician progress notes included a section for memory testing under the mental status examination section of the note.

3. Patient C14: In the Mental Status section of the Admission Psychiatric Evaluation written 8/27/11 there was no entry for "Memory." Review of daily Psychiatric Progress Notes after the date of admission failed to identify any memory testing being completed by the physician even though the preprinted form for physician progress notes included a section for memory testing under the mental status examination section of the note.

4. Patient D3: In the Mental Status section of the Admission Psychiatric Evaluation written 8/27/11, the following was noted for "Memory": "Unable to assess." Review of daily Psychiatric Progress Notes after the date of admission failed to identify any memory testing being completed by the physician even though the preprinted form for physician progress notes included a section for memory testing under the mental status examination section of the note.

5. Patient D7: In the Mental Status section of the Admission Psychiatric Evaluation written 8/21/11, the following was noted for "Memory": "Unable to assess." Review of daily Psychiatric Progress Notes after the date of admission failed to identify any memory testing being completed by the physician even though the preprinted form for physician progress notes included a section for memory testing under the mental status examination section of the note.

B. Interview

In an interview on 9/1/11 at 2:00pm, the Medical Director was shown three examples (C3, C4 and C14) of the psychiatric evaluations noted above. She stated, "This is probably a problem with our new on call doctor not knowing what to do." In discussing the missing information in the daily progress notes by attending physicians for the sample patients, she stated, "I guess we're just not doing it as a group."




25352

Based on observation, record review and interview, the facility failed to develop and document comprehensive multidisciplinary treatment plans to address presenting problems for 3 of 8 active sample patients (C3, E4 and E6) and one of 14 non-sample patients reviewed (C13) to direct staff in the care of these patients. This failure results in fragmented treatment, without orientation to each patient's goals.

Findings include:

A. Patient C3:

1. Patient C3 was admitted to the facility on 8/29/11 and was placed in mechanical restraints later that day for aggression/violence toward others.

2. Review of the problem on Patient C3's master treatment plan (dated 8/29/11) titled "Risk for Restraints" revealed that this plan included interventions stated as generic, role functions, rather than specific medications and nursing interventions based on individual patient behaviors to prevent and care for the patient if/when aggression reoccurred.

a. Physician interventions included all four generic, role functions on the preprinted form without individualization:
"Assess/adjust medications efficacy during each visit and/or as needed.
Provide directions for use of psychoactive medications to reduce/eliminate the need for (remaining words left off form).
Obtain informed consent for psychoactive medications. prior (sic) to initiating each.
Monitor and educate regarding precautions, risks, benefits, and side effects of medications. during visit (sic)."

b. Nursing interventions included the following generic, role functions without individualization.
"2 group or 1:1 x [blank] days to provide education related to stress/anger management techniques to augment coping skills.
Provide medication education prior to initiation of therapy and as needed during continuations of same each time of each administration.
Use de-escalation techniques to prevent aggression-acting out or violent episodes whenever signs of escalation appear.
Use non-violent crisis intervention techniques (words omitted) less restrictive interventions have been unsuccessful."

B. Patient E4 was a geriatric patient admitted on 8/8/11 with the diagnosis of Alzheimer's dementia with behavioral disturbance.

1. Observations of Patient E4 on 8/31/11 at 10:50a.m. and on 9/1/11 at 1:15p.m. revealed that this patient presented with confusion and impaired memory. Staff constantly followed the patient around the ward, redirecting as needed. During interview on 8/31/11 at 11:30a.m., Patient E4 was unable to answer direct questions, stating "I have to go see about the baby."

2. Review of Patient E4's master treatment plan, dated 8/8/11 with latest revision on 8/26/11, revealed that the plan failed to address this patient's confusion and severe memory impairment.

3. During interview on 9/1/11 at 11:40a.m., Physician 1 verified that Patient E4's confusion and impaired memory were not addressed in the master treatment plan.

C. Patient E6 was a geriatric patient admitted on 8/29/11 with the diagnosis of Alzheimer's dementia with behavioral disturbance.

1. Observations of Patient E6 on 8/31/11 at 10:50a.m. and on 9/1/11 at 1:15p.m. revealed that this patient presented with confusion and impaired memory. During interview on 8/31/11 at 10:55a.m., Patient E6 was able to answer some direct questions, but exhibited confusion and impaired memory.

2. Review of Patient E6's master treatment plan (dated 8/24/11 with latest revision on 8/25/11) revealed that the plan failed to address this patient's confusion and severe memory impairment.

3. During interview on 9/1/11 at 11:40a.m., Physician 1 verified that Patient E4's confusion and impaired memory were not addressed in the master treatment plan.

D. Patient C13 was a young adult involuntarily admitted to the facility on 8/18/11 with a diagnosis of Psychosis NOS.

1. During an observation on 8/31/11 at 10:15am, Patient C13 was lying in bed resting while most other patients (approximately 9) were attending a unit group activity. Patient C13 stated, "I'm tired. My medications knock me out." In an interview on 9/1/11 at 1:45pm, Patient C13 described his/her hospital stay as "I just want to be discharged and go home so I can start college. The problem is I'm so sedated from medication that I can't get to groups. The nurses and doctor said that if I don't take all of my medications then I can't go home, but if I take medication then I get tired and miss groups. When I miss groups they (staff) tell me I'm not involved in treatment so I can't go home. At this point I'll never get out of here." When asked about medications, Patient C13 stated that "the three medicines they give me (Haldol, Ativan and Benadryl together), I get in trouble because I have a loud voice and the nurses don't like it, they just give it (medications) to me to knock me out."

2. Review of Patient C13's Medication Administration Record (MAR) noted that the patient's psychosis was being treated with routine dosing of an antipsychotic. The MAR showed that the patient had received all doses of the antipsychotic since admission. The "PRN Medications" page of the MAR noted that Patient C13 had also been ordered doses of Haldol (sedating antipsychotic) 5 mg q4hrs (every 4 hours) PO/IM (oral/intramuscular) PRN (as needed) psychosis; Ativan (sedating benzodiazepine) 2 mg PO/IM q4hrs PRN agitation/anxiety and Benadryl (sedating antihistamine) 50 mg PO/IM q4hrs PRN EPS (extrapyramidal symptoms). The MAR showed that the patient received dosing of Haldol, Ativan and Benadryl on 8/19/11 (2:30pm); 8/22/11 (1:00pm); 8/27/11 (2:00am); 8/28/11 (1:40am and 12 noon); 8/29/11 (12:15am); 8/30/11 (2:10am and 11:30am); 9/1/11 (9:00am). Patient C13 also received Ativan alone on 8/23/11 (1:30pm); 8/24/11 (3:50am) and 8/25/11 (6:05pm).

3. Review of Group Notes revealed the following:

a. Group Therapy note dated 8/22/11 at 10:00am noted "Patient was sleep in room. Patient did not participate. (sic)"; 8/22/11 at 11:00am noted "Sleeping."; 8/22/11 at 4:15pm noted "Sleeping in room, Patient refused to attend."

b. Group Therapy note dated 8/24/11 at 1:00pm noted "Patient slept through most of the group."

c. Group Therapy note dated 8/25/11 at 1:00pm noted "...Patient left group early stating [s/he] was extremely tired and wanted to lie down."

d. Social Work Group Therapy note dated 8/27/11 at 1:00pm noted "Attended, but did not participate, Sleeping." "Patient stated [his/her] meds are pretty strong, but did want to go lay down."

4. Review of the Master Treatment Plan dated 8/20/11 identified Medication Non-compliance as a problem, although the MAR showed that Patient C13 never refused any medication dosing; but failed to identify patient's sedation and inability to participate in treatment as a problem,

5. During an observation of the Unit C treatment team meeting on 9/1/11 at 9:00am, Patient C13 was discussed. RN1 stated that "[Patient C13] wasn't attending groups because of sedation; [s/he] had been given the cocktail each day (referring to Haldol, Ativan and Benadryl)." The treatment team did not discuss any modification to the treatment plan to address the issue.

Based on record review and interview, the facility failed to develop master treatment plans that identified clearly delineated physician, nursing and social work interventions to address the specific treatment needs of 8 of 8 active sample patients (C3, C4, C10, C14, D3, D7, E4 and E6.) Interventions were chosen from a preprinted list, the majority being routine, generic discipline functions, without information added to individualize the plans based on patient needs. This failure results in similar or identical master treatment plans that fail to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment for each patient.

Findings include:

A. Review of the master treatment plans of the following 8 sample patients (dates of plans in parentheses): C3 (8/29/11); C4 (8/19/11); C10 (8/22/11); C14 ( 8/27/11); D3 (8/26/11); D7 (8/20/11); E4 (8/8/11 with latest revision on 8/26/11) and E6 (8/24/11 with latest revision on 8/25/11) revealed the following findings:

1. Patients C4, D3, D7, E4 and E6:

For the problem identified as "Depressive Symptoms"

a. Physician interventions included all three generic, role functions on the preprinted form for each patient without individualization, other than number of times to be performed:

"Assess and adjust medications ___ times per week and/or as needed.
See patient on an individual basis __ times per week for supportive therapy and to assess level of depressive symptoms.
Monitor and educate regarding precautions, risks, benefits, and side effects of medications."

b. Nursing interventions included the following generic, role functions for each patient without individualization, other than number of times to be performed.

"Monitor for medication side effects and effectiveness of teaching regarding precautions, benefits, and discharge medication regimen at least __.
Direct and assist patient to groups and activities each shift.
Redirect patient for intrusiveness or inappropriateness with peers, set limits as needed."

c. Social Worker/Case Management/Therapist interventions included the following generic, role functions for each patient without individualization, other than number of times to be performed.

"Meet with patient __ times per week to encourage verbalization while assessing depressive symptoms and offering support and education related to diagnosis.
Group __times per week, for education regarding depressive behavior, coping skills, and therapy.
Family contact __ times for education related to depressive behavior discharge needs, and reintegration into family system.
Coordinate discharge placement, aftercare, and community resources."

2. Patients C3, C10 and C14:

For the problem identified as "Psychotic Symptoms: Delusional Thoughts"

a. Physician interventions included the following generic, role functions for each patient without individualization.

"Assess and adjust medication efficacy during each visit and/or as needed.
See patient on an individual basis during (sic) each visit to assess status of delusions.
Monitor and educate regarding precautions, risks, benefits, and side effects of medications." (This last intervention was checked twice, with "during each visit" added to one of these statements on the preprinted form.)

b. Nursing interventions included the following generic, role functions for each patient without individualization other than number of times to be performed.

"Reorient to time, place person (sic) whenever delusional symptoms interfere w/ [with] reality contact.
Work together with pt [patient] & team to identify symptoms which are problematic- i.e. Pressured (sic) speech, intrusiveness, grandiose thoughts suspitcions (sic) of others."
Engage pt [patient] in partnership w/ staff agreeing to point out symptoms and bring to patient's attention as these occur.
After agreement is established, help pt. achieve control of symptoms as they occur through each 1:1 and/or group interaction.
Provide medication education prior to initiation of therapy and as needed during continuation of same at time of each administration.
Monitor and document any factors contributing to disorientation or precipitants to delusions."

c. Social Worker/Case Management/Therapist interventions included the following generic, role functions for each patient without individualization, other than number of times to be performed.

"Gently confront illogical thoughts and speech to refocus disordered thinking.
See patient __ times per week for trust building; approach patient in non-threatening manner providing positive affirmation and reassurance.
__Groups __ days per week for support and education regarding delusions, recovery and relapse prevention."

3. Patients C4, C10, D3 and E4:

For the problem identified as "Suicide Thoughts/Plan/Attempts"

a. Physician interventions included all four generic, role functions on the preprinted form for each patient without individualization, other than number of times to be performed.

"Assess and adjust medications __ times per week.
Individual therapy __ times/week.
Monitor for therapeutic medication levels.
Obtain informed consent for psychoactive medication prior to initiating each."

b. Nursing interventions included the following generic, role functions for each patient without individualization, other than number of times to be performed.

"Assess patient through 1:1 contact for suicidal ideation and precaution level every shift.
Assist patient in developing relapse and crisis plan, addressing how he/she would handle suicidal ideation after discharge.
Educate patient/family regarding disease process __ times, reinforcing as needed.
Monitor and check for medication as prescribed for ingestion, "cheeking" etc. at each administration.
Provide/maintain safe environment."

c. Social Worker/Case Management/Therapist interventions included the following generic, role functions for each patient without individualization, other than number of times to be performed.

"Coordinate discharge placement, aftercare, and community resources.
Provide opportunities to increase self-worth through positive affirmations and success-oriented activities in group settings __ times/week.
Provide opportunities to increase self-worth through positive affirmations and success-oriented activities in 1:1 settings __ times/week."

4. Patients C3, C4 and D7:

For the problem identified as "Substance Abuse Withdrawal"

a. Physician interventions included all six generic, role functions on the preprinted form for each patient without individualization, other than number of times to be performed.

"Provide orders for medications for safe withdrawal and monitor signs and symptoms daily.
Provide at least __options for strategizing on-going recovery.
Adjust detoxification medication protocols as necessary related to increasing or decreasing signs and symptoms of withdrawal daily.
Obtain thorough history of patient's use and abuse during 1:1 interview/s at least __ x during stay, and record.
Assist nursing and social work staff with discharge planning and continuing care options within __ days of hospitalization.
Obtain informed consent for psychoactive medications prior to initiating each."

b. Nursing interventions included the following generic, role function for each patient without individualization, other than number of times to be performed.

"Monitor vital signs at least every __ hrs. second and third day of stay and medicate as ordered for symptoms of withdrawal as these appear, at least every __ hrs."

c. Social Worker/Case Management/Therapist interventions included all three generic, role functions on the preprinted form for each patient without individualization, other than number of times to be performed.

"Provide 1:1 discussion time at least __ x every __ days to allow for ventilation of fears thoughts and cravings related to withdrawal from substance of choice.
Provide group education and continuing care strategies for maintenance of recovery at least __ during stay.
Meet with pt/family at least __ x during stay to establish communication and plan for discharge/continuing care options."

B. Interviews:

1. During interview on 8/31/11 at 1:50p.m., RN 1 verified that the nursing interventions on the treatment plans for Patients C3 and C14 were not individualized based on patient needs.

2. During interview on 9/1/11 at 2:00p.m., the Medical Director stated that the treatment plan interventions were not individualized based on patient needs. She stated, "The plan does not reflect what is going on with the patients."

3. During interview on 9/1/ at 3:40p.m., the Director of Nursing stated that the nursing interventions on the treatment plans were not individualized.




18051

21993

Based on observation, interview and document review, the facility failed to:

I. Ensure that patients were able to participate in active programming on Unit C. Patients were over-medicated through the use of PRN (as needed) sedating medications for one of four active sample patients (C3), and one of 14 non-sample patients chosen for review of medication usage (C13) on Unit C. Both patients complained that they were unable to participate in unit activities secondary to over sedation. This failure may unnecessarily prolong a patient's hospitalization.

II. Ensure that physician orders provided adequate guidance to nursing staff on the administration of antipsychotic, antianxiety and/or pain medications for 4 of 8 active sample patients (C3, C4, C10 and C14) and for 9 of 14 non sample patients (C1, C2, C5, C6, C8, C13, C15, C16 and C17) added for medication order review. For these patients, physician orders were written on a PRN (as necessary) basis for "anxiety", "psychosis" or "EPS" (extrapyramidal symptoms) with no specification of the delivery method. Nurses could choose to administer the same dose of medications by "IM" (intramuscular injection) or "p.o." (orally), and failed to document the rationale for the route of administration of the medications when used. Additionally, 1 of 8 active sample patients (C10) and 2 of 14 non- sample patients (C9 and D4) each had PRN orders for at least two different medications for identical indications, without specific guidance to nursing as to which medication to use. These failures place the nursing staff in a situation that requires them to function beyond the scope of nursing practice. Ambiguous physician orders can result in serious complications from improperly administered PRN medications.

III. Ensure that when medications were used which decreased patient participation in treatment they were recognized as chemical restraint, for one of eight active sample patients (C3) and one of fourteen non-sample patients (C13) reviewed for medication usage. Nursing staff administered medications that resulted in the patients missing group therapies and/or sleeping during groups. These medications were being used to control behaviors per nursing notes and interviews. Nursing staff failed to recognize these events as chemical restraint and did not complete seclusion/restraint documentation for the patient. This failure violates a person's right to be free of restrictive measures without justification.

IV. Ensure that sensitive patient information was protected from being overheard for 2 non-sample patients, including E8. Patient E8's daughter was informed of the patient's condition, treatment and discharge plans by the attending physician in the Ward E day area with other patients present. The second example occurred when the attending physician was dictating over the phone an admission history while standing in the Ward C day area with 2 non-sample patients standing nearby. These failures to protect patient privacy place patients at risk for confidential information to be disseminated among their peers and can lead to an impediment for continued treatment if patients cannot trust staff to respect their privacy

Findings include:

I. Use of Sedating Medications i:

A. Patient C3 was a young adult admitted to the facility on 8/29/11 at 11:20a.m. with the diagnosis of Schizoaffective Disorder.

Facility preprinted "Adult Admission Orders" form noted the following orders under the section titled "Medications":
"Haldol 5mg PO/IM [orally/intramuscular] q6hrs [every six hours] PRN [as needed] psychosis OR (if known allergy or sensitivity to Haldol) Thorazine 100mg PO/IM q4hrs [every 4 hours] PRN psychosis."
"Dipenhydramine [sic] 50mg PO/IM q6hrs PRN for EPS [extrapyramidal symptoms] OR (if known allergy or sensitivity to Dipenhydramine [sic]) Cogentin 1mg PO/IM q6hrs PRN EPS."
"Ativan 1mg PO/IM q6hrs PRN anxiety/agitation."

1. Review of Patient C3's Medication Administration Record (MAR) noted that on 8/29/11 at 1:20p.m., Patient C3 was given Haldol 5mg IM and Benadryl 50 mg IM for aggressive behavior on C Ward (Adult Psychiatry). This patient then received Haldol 5 mg PO, Benadryl 50mg PO and Ativan 2mg PO at 3:10pm (less than the 6 hours ordered between dosing).

2. Review of the Daily Observation Form for Patient C3 on 8/29/11 revealed that Patient C3 was in the unit "quiet room" from 3:00pm to 11:00pm either sleeping or lying on the bed. Daily Observation Form dated 8/30/11 noted that Patient C3 was still in the unit "quiet room" from 11:00pm (8/29/11) to 5:45am (8/30/11). Staff noted that the patient was lying on the bed the entire duration. During the period of time from 8/29/11 at 3:00pm to 8/30/11 at 11:00pm (32 hours total), Patient C3 attended one therapy group at 3:00pm on 8/30/11 and spent a total of 5 hours in the unit milieu areas (day area and group room), otherwise Patient C3 was noted to be either sleeping or lying on the bed.

3. Group Therapy note dated 8/29/11 at 4:15pm noted that Patient C3 did not attend group secondary to "sleeping." On 8/30/11 the patient missed groups at 10am, 11am, 1pm, 2pm and 6:30pm.

4. During an interview on 9/1/11 at 11:25a.m., Patient C3 stated, "I got a shot in my arm and one in my butt. It put me to sleep 'til the next day. I stayed in that quiet room (restraint room) a long time."

B. Patient C13 was a young adult involuntarily admitted to the facility on 8/18/11 with a diagnosis of Psychosis NOS.

1. During an observation on 8/31/11 at 10:15am, Patient C13 was lying in bed resting while most other patients (approximately 9) were attending a unit group activity. Patient C13 stated, "I'm tired. My medications knock me out."

2. Review of Patient C13's Medication Administration Record (MAR) noted that the patient's psychosis was being treated with routine dosing of an antipsychotic. The MAR showed that the patient had received all doses of the antipsychotic since admission. The "PRN Medications" page of the MAR noted that Patient C13 had also been ordered doses of Haldol (sedating antipsychotic) 5mg q4hrs (every 4 hours) PO/IM (oral/intramuscular) PRN (as needed) psychosis; Ativan (sedating benzodiazepine) 2mg PO/IM q4hrs PRN agitation/anxiety and Benadryl (sedating antihistamine) 50mg PO/IM q4hrs PRN EPS (extrapyramidal symptoms). The MAR showed that the patient received dosing of Haldol, Ativan and Benadryl on 8/19/11 (2:30pm); 8/22/11 (1:00pm); 8/27/11 (2:00am); 8/28/11 (1:40am and 12 noon); 8/29/11 (12:15am); 8/30/11 (2:10am and 11:30am); 9/1/11 (9:00am). Patient C13 also received Ativan alone on 8/23/11 (1:30pm); 8/24/11 (3:50am) and 8/25/11 (6:05pm).

3. In an interview on 9/1/11 at 1:45pm, Patient C13 described his/her hospital stay as "I just want to be discharged and go home so I can start college. The problem is, I'm so sedated from medication that I can't get to groups. The nurses and doctor said that if I don't take all of my medications then I can't go home, but if I take medication then I get tired and miss groups. When I miss groups they (staff) tell me I'm not involved in treatment so I can't go home. At this point I'll never get out of here." When asked about medications, Patient C13 stated that "the three medicines they give me (Haldol, Ativan and Benadryl together), I get in trouble because I have a loud voice and the nurses don't like it, they just give it (medications) to me to knock me out."

4. Review of Nursing Assessments:

a. Daily Nursing Assessment form dated 8/28/11 at 2:00pm noted: "Patient anxious, wants to be transferred to Unit D, using cursing word, wrote a grievance. Offered po prn Ativan, Haldol, and Benadryl but refused. IM prn on the right deltoid voluntarily without resist. (sic)" Mental Status check boxes showed that nursing marked off "No" for hallucinations and delusions, "Organized" for thoughts. Affect was checked off as "blunted."

b. Daily Nursing Assessment form dated 8/30/11 at 3:00pm noted: "Patient is loud, agitated and angry that 'I'm still locked up in here. I'm tired of this. I ain't no quiet person.' Patient is given PRN Haldol 5mg, Ativan 2mg, and Benadryl 50mg after verbal redirection is not effective. Patient ate lunch then went to sleep."

5. Review of Group Notes:

a. Group Therapy note dated 8/22/11 at 10:00am noted: "Patient was asleep in room. Patient did not participate. (sic)"; 8/22/11 at 11:00am noted "Sleeping"; 8/22/11 at 4:15pm noted "Sleeping in room, Patient refused to attend."

b. Group Therapy note dated 8/24/11 at 1:00pm noted: "Patient slept through most of the group."

c. Group Therapy note dated 8/25/11 at 1:00pm noted "Patient completed worksheet on becoming aware of one's moods and shared responses with the group. Patient left group early stating [s/he] was extremely tired and wanted to lie down."

d. Social Work Group Therapy note dated 8/27/11 at 1:00pm noted "Attended, but did not participate, Sleeping." "Patient stated [his/her] meds are pretty strong, but did want to go lay down."

6. During an observation of the Unit C treatment team meeting on 9/1/11 at 9:00am, Patient C13 was discussed. RN1 stated that "[Patient C13] wasn't attending groups because of sedation; [s/he] had been given the cocktail each day (referring to Haldol, Ativan and Benadryl)." II. Ambiguous Medication Orders

II. Documentation related to medication orders:

A. Ambiguous orders related to route of administration:

1. Facility preprinted "Adult Admission Orders" form noted the following orders under the section titled "Medications":
"Haldol 5mg PO/IM [orally/intramuscular] q6hrs [every six hours] PRN [as needed] psychosis OR (if known allergy or sensitivity to Haldol) Thorazine 100mg PO/IM q4hrs [every 4 hours] PRN psychosis."
"Dipenhydramine [sic] 50mg PO/IM q6hrs PRN for EPS [extrapyramidal symptoms] OR (if known allergy or sensitivity to Dipenhydramine [sic]) Cogentin 1mg PO/IM q6hrs PRN EPS."
"Ativan 1mg PO/IM q6hrs PRN anxiety/agitation."

2. Facility preprinted "Geriatric Admission Orders" form noted the following orders under the section titled "Medications":
"Dipenhydramine [sic] 25mg PO/IM q6hrs PRN for EPS."
"Ativan 0.5mg PO/IM q6hrs PRN anxiety/agitation."

3. Record Review:

Review of the Medication Administration Records (MAR) of all of the patients on Unit C (acute adult unit) on 9/1/11 noted that 13 of 18 Unit C patients (C1, C2, C3, C4, C5, C6, C8, C10, C13, C14, C15, C16 and C17) including all 4 active sample patients (C3, C4, C10 and C14) had orders written for administration of all three medications noted in part 1 above. Ten of the 13 (C2, C3, C4, C5, C6, C8, C10, C13, C14 and C15) Unit C patients had received simultaneously all three drugs at least one time during their hospitalization including all 4 active sample patients (C3, C4, C10 and C14).

a. Patient C2 admitted 8/26/11 with a diagnosis of Psychosis NOS (Admission Psychiatric Exam dated 8/27/11). The patient's MAR noted that Patient C2 received Haldol 5mg PO, Benadryl 50mg PO and Ativan 1mg PO 6 times between 8/26/11 and 8/29/11; on 8/27/11 Haldol and Benadryl were given without Ativan. There was no nursing documentation to describe the rationale for using the PRN medications as given.

b. Patient C3 admitted 8/29/11 with a diagnosis of Schizoaffective Disorder (Admission Psychiatric Exam dated 8/29/11): the patient's MAR on 8/29/11 noted that the patient had received Haldol 5mg IM and Benadryl 50mg IM at 1:20pm and then received Haldol 5mg PO, Benadryl 50mg PO at 3:10pm (less than 6 hours as ordered between dosing). In addition, the patient received Ativan 2mg PO with the other two medications at 3:10pm. There was no documentation by nursing to describe the rationale for the choice of medication or route of administration.

c. Patient C4 was admitted 8/19/11 with a diagnosis of Major Depression without psychotic features (Admission Psychiatric Exam dated 8/20/11). In the patient's MAR it noted that Patient C4 received Haldol 5mg PO and Benadryl 50mg PO (no Ativan) on 8/20/11 at 9:00am; Haldol 5mg PO and Benadryl 50mg PO on 8/21/11 at 1:00pm (no Ativan); Haldol 5mg PO, Benadryl 50mg and Ativan 1mg PO on 8/30/11 at 5:25pm. There was no documentation made by nursing describing rationale for using the medications in different combinations.

d. Patient C5 admitted 8/19/11 with a diagnosis of Psychosis NOS (Admission Psychiatric Exam dated 8/19/11): the patient's MAR noted that Patient C5 received Haldol 5mg PO, Cogentin 1mg PO and Ativan 2mg PO 2 times between 8/25/11 and 8/27/11. For the episode on 8/25/11, Patient C5 received Haldol 5mg PO and Ativan 2mg without Cogentin; for the episode on 8/27/11, Patient C5 was given Ativan 2mg PO and Cogentin 1mg PO without Haldol. There was no nursing documentation to describe the rationale for using the PRN medications as given.

e. Patient C6 admitted 8/20/11 with a diagnosis of Schizophrenia with acute psychosis (Admission Psychiatric Exam dated 8/21/11): the patient's MAR noted that Patient C6 received Haldol 5mg PO and Ativan 1mg PO on 8/20/11 at 11:15pm without Diphenhydramine. There was no nursing documentation to describe the rationale for using the PRN medications as given.

f. Patient C8 admitted 8/22/11 with a diagnosis of Mood Disorder with Psychotic Features (Admission Psychiatric Exam dated 8/23/11): the patient's MAR noted that Patient C2 received Haldol 5 mg PO, Benadryl 50 mg PO and Ativan 1mg PO 3 times between 8/23/11 and 8/27/11. There was no nursing documentation to describe the rationale for using the PRN medications as given.

g. Patient C10 was admitted 8/22/11 with a diagnosis of Bipolar Disorder with psychotic features (Admission Psychiatric Exam dated 8/23/11). The patient's MAR noted that Patient C10 received Haldol 5mg PO, Benadryl 50mg PO and Ativan 1mg PO on 8/26/11 at 1:20am; Haldol 5mg PO with Benadryl 50mg PO again on 8/26/11 at 12:20pm (no Ativan given); Haldol 5mg PO, Benadryl 50mg PO and Vistaril 50mg on 8/27/11 at 8:00am and then the same medications again at 6:00pm. There was no documentation by nursing to describe the rationale for the choice of medication or route of administration.

h. Patient C13 admitted 8/18/11 with a diagnosis of Psychosis NOS (Admission Psychiatric Exam dated 8/19/11): the patient's MAR noted that Patient C13 received Haldol 5mg PO, Benadryl 50mg PO and Ativan 2mg PO 7 times between 8/19/11 and 8/30/11; one episode was IM instead of PO on 8/28/11 at 12:00pm. Patient C13 received three doses of Ativan PO alone between 8/23/11 and 8/25/11. There was no nursing documentation to describe the rationale for using the PRN medications as given.

i. Patient C14 admitted 8/27/11 with a diagnosis of Psychosis NOS (Admission Psychiatric Exam dated 8/27/11): in the patient's MAR it was noted that Patient C14 received Haldol 5mg PO, Benadryl 50mg PO and Ativan 1mg PO on 8/28/11 at 7:30am. Nursing notes did not document the rationale for using all three drugs at the same time.

j. Patient C15 admitted 8/4/11 with a diagnosis of Schizoaffective Disorder (Admission Psychiatric Exam dated 8/5/11): the patient's MAR noted that Patient C15 received Haldol 5mg PO, Benadryl 50mg PO and Ativan 1mg PO one time on 8/30/11. There was no nursing documentation to describe the rationale for using the PRN medications as given.

B. Different medication orders for the same indication:

1. Patient C9 was admitted 8/26/11 with a diagnosis of Chronic Paranoid Schizophrenia (Admission Psychiatric Exam dated 8/27/11). The patient's MAR noted the following: Motrin 800mg PO q6hrs PRN pain, and also Oxycodone IR (Immediate Release) 15mg q8hrs PRN pain. There were no physician directions regarding how to use either drug on an as needed basis.

2. Patient C10: Patient C10 had orders for two PRN medications to be given for "anxiety": Vistaril 50mg PO q6hrs PRN anxiety and Ativan 1mg PO/IM q6hrs PRN anxiety. There were no physician directions included that guided nurses related to how to use each drug. Patient C10 received 15 doses of PRN Vistaril between 8/23/11 and 8/31/11. During the same time frame, Patient C10 received 2 doses of Ativan (8/26/11 and 8/29/11). There were no nursing notes that documented the rationale for choosing either drug.

3. Patient D4 was admitted 8/29/11 (diagnosis not available). The patient's MAR noted the following medications for the same PRN indication of "anxiety": Xanax 0.5mg PO q12hrs PRN anxiety and Vistaril 50mg PO q6hrs PRN anxiety. There were no physician directives to explain how to use each drug noted in the record. Between 8/29/11 and 9/1/11, Patient D4 received 6 doses of Xanax and 5 doses of Vistaril without any nursing documentation that explained the rationale for using either drug.

C. Interviews

1. In an interview on 8/31/11 at 10:30am, RN1 and RN2 were asked how they decide which PRN medication to give when there are multiple drugs ordered for the same indication; both nurses stated, "usually the patient knows which drug they want." In a follow-up query, RN1 and RN2 were asked about how they decide to give 2 or 3 PRN medications at the same time without physician direction; RN1 stated that "the Doctors usually want us to give all three medications at the same time; occasionally we use our own judgment to decide which drugs to use." When asked about orders utilizing two routes of administration without physician direction, RN2 stated "we try to give the meds PO but if the patient can't take PO or refuses, then we can hold the patient down and give an IM, and sometimes the patient asks for a needle instead of pills."

2. In an interview on 8/31/11 at 11:45am, MD2 stated, "we order all three drugs [referring to Haldol, Ativan and Benadryl] on admission to save the nurses from calling us for one time orders....."

3. In an interview on 8/31/11 at 2:30pm, the Director of Nursing agreed that the orders for two different medications for the same indication were ambiguous and that there wasn't clear direction from the ordering physician as to how to use the medications. She also stated that giving the orders with a choice of route [PO/IM] "places nurses in a position of making medical decisions."

4. In an interview on 9/1/11 at 1:05p.m., when asked how nursing staff utilize the PO/IM medication orders, RN3 stated, "If they (patients) refuse PO, and there is a risk of their hurting self or others, I then give it IM." RN3 reported that s/he had followed this practice since employed in this facility, and stated that these were "inappropriate physician orders."

5. In an interview on 9/1/11 at 1:35pm, when asked about how staff decide to give Haldol, Ativan and Benadryl, Patient C13 stated "I get different medications all the time, it depends on which nurse is working that day."

6. In an interview on 9/1/11 at 1:45pm, Patient C9 was asked about the orders for two different pain medications. Patient C9 stated "I chose Oxycodone over Motrin every time, it works for me."

7. In an interview on 9/1/11 at 2:15pm, the Medical Director agreed that there was no clear direction from physicians to nursing staff related to the choice of route or different medications for the same indication. She stated "we've done it this way for years."

III. Use of Chemical Restraint

A. Patient C3 was a young adult admitted to the facility on 8/29/11 at 11:20a.m. with the diagnosis of Schizoaffective Disorder.

1. Review of Patient C3's Medication Administration Record (MAR) noted that on 8/29/11 at 1:20p.m., Patient C3 was given Haldol 5mg IM and Benadryl 50mg IM at the same time that he was placed in mechanical restraint for aggressive behavior on C Ward (Adult Psychiatry). This medication was not documented as a chemical restraint. This patient then received Haldol 5mg PO, Benadryl 50mg PO and Ativan 2 mg PO all at 3:10pm (less than the 6 hours ordered between dosing), again without proper documentation.

2. Review of the Daily Observation Form for Patient C3 on 8/29/11 revealed that Patient C3 was in the unit "quiet room" from 3:00pm to 11:00pm either sleeping or lying on the bed. Daily Observation Form dated 8/30/11 noted that Patient C3 was still in the unit "quiet room" from 11:00pm (8/29/11) to 5:45am (8/30/11). Staff noted that the patient was lying on the bed the entire duration. During the period of time from 8/29/11 at 3:00pm to 8/30/11 at 3:00pm, Patient C3 attended one therapy group at 3:00pm on 8/30/11, otherwise Patient C3 was noted to be either sleeping or lying on the bed.

3. Group Therapy note dated 8/29/11 at 4:15pm noted that Patient C3 did not attend group secondary to "sleeping." On 8/30/11 the patient missed groups at 10am, 11am, 1pm, 2pm and 6:30pm.

4. During an interview on 9/1/11 at 11:25a.m., Patient C3 stated, "I got a shot in my arm and one in my butt. It put me to sleep 'til the next day. I stayed in that quiet room (restraint room) a long time." Patient C3 felt that there was no other choice than to take the medications nurses gave him/her.

B. Patient C13 was a young adult involuntarily admitted to the facility on 8/18/11 with a diagnosis of Psychosis NOS. For the details of the patient's treatment see Section I above.

1. In an interview on 8/31/11 at 11:45am, MD2 noted the admission orders for the medications given patient C13 included preprinted PRNs (Haldol. Ativan and Benadryl) "so that nursing has meds available to calm patients down quickly and not have to call the doctor." When asked why these medications were used instead of using additional medication dosing with the patient's routine medications, MD2 stated, "this combination knocks people out more quickly and we've used it a long time and it works." Asked specifically about Patient C13, MD2 stated "[C13] gets loud at times, so we give the PRNs."

2. During an observation of the Unit C treatment team meeting on 9/1/11 at 9:00am, Patient C13 was discussed. RN1 stated that "[Patient C13] wasn't attending groups because of sedation; [s/he] had been given the cocktail each day [during that week; and referring to Haldol, Ativan and Benadryl]."

3. During an interview on 9/1/11 at 2:15pm, the Medical Director stated that the combination of sedating medications (Haldol, Ativan and Benadryl) "Have been used for a long time to control behavior, we didn't think it was a problem." The facility seclusion and restraint policy was discussed with respect to the definition of chemical restraint; the Medical Director agreed that the use of the combination of medications for Patient C13 met the definition. When asked if physicians and nurses have documented chemical restraint in these circumstances, the Medical Director stated, "I guess not."

C. Facility Policy Review:

Facility Policy TX 7.1 titled "Seclusion and Restraint", effective 05/96 and last revised 06/07 noted under the section for "Definitions" the following: "Restraint: any drug or medication when it is used as a restriction to manage patient behavior or restrict patient freedom of movement and is not a standard treatment or dosage for the patient's condition." Under the section titled "Basic Principles and Rationale" noted "PRN orders are never written for seclusion or restraint." The policy did not provide any further information for staff related to the use of chemical restraint and did not identify how to document episodes of chemical restraint.

IV. Failure to ensure patient privacy:

A. Observations:

1. Observation of the Ward D (Senior Behavioral) on 8/31/11 at 11:15a.m. revealed MD 1 and an RN (name unknown) talking to the daughter of non-sample Patient E8 at the nursing station about the medications and treatment of that patient. This conversation took place with several patients sitting in the immediate area.

2. During an observation on Ward C (Adult Psychiatry) on 9/1/11 at 1:15pm, MD1 was standing on the patient side of the nursing station counter dictating a patient's psychiatric admission note over the telephone for approximately 5 minutes. The content of the patient's history was clearly audible to the surveyor who was standing next to non-sample Patient C5 at the time. The information that MD1 related over the phone included confidential patient information.

B. Interviews

1. In an interview on 9/1/11 at 1:25pm, Patient C5 was asked if s/he had overheard the physician on the phone. Patient C5 stated "yes." Patient C5 was asked if s/he felt the information should have been kept private and C5 stated, "I didn't like having the doctor talk on the phone about patients in front of me. Here (Ward C) it happens all the time."

2. In an interview on 9/1/11 at 2:30pm, MD1 acknowledged that they had dictated on the phone in the Ward C day area and that patients could have overheard the information. MD1 stated, "that the units have a bad layout for privacy, there's really nowhere around the nurse's station where confidentiality could be completely safe."

I. Ensure that physicians performed and documented an estimate of memory functioning in 5 of 8 sampled psychiatric evaluations (C3, C4, C14, D3 and D7). The failure to document specific testing compromises the identification of pathology which may be pertinent to the current mental illness and compromises future comparative re-examination to assess patient's response to treatment interventions. (Refer to B116)

II. Develop and document comprehensive multidisciplinary treatment plans to address presenting problems for 3 of 8 active sample patients (C3, E4 and E6) and one of 14 non-sample patients reviewed (C13) to direct staff in the care of these patients. This resulted in fragmented, non-goal directed treatment. (Refer to B118)

III. Develop master treatment plans that identified clearly delineated physician, nursing and social work interventions to address the specific treatment needs of 8 of 8 active sample patients (C3, C4, C10, C14, D3, D7, E4 and E6). Interventions were chosen from a preprinted list (the majority being routine, generic discipline functions) without information added to individualize the plans based on patient needs. This failure results in similar or identical master treatment plans that fail to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment for each patient. (Refer to B122.)

IV. Ensure that patients were able to participate in active programming on Unit C. Patients were over-medicated through the use of PRN (as needed) sedating medications for one of four active sample patients (C3), and one of 14 non-sample patients chosen for review of medication usage (C13) on Unit C. Both patients complained that they were unable to participate in unit activities secondary to over sedation. This failure may unnecessarily prolong a patient's hospitalization. (Refer to B125, Part I.)

V. Ensure that physician orders provided adequate guidance to nursing staff on the administration of antipsychotic, antianxiety and/or pain medications for 4 of 8 active sample patients (C3, C4, C10 and C14) and for 9 of 14 non sample patients (C1, C2, C5, C6, C8, C13, C15, C16 and C17) added for medication order review. For these patients, physician orders were written on a PRN (as necessary) basis for "anxiety", "psychosis" or "EPS" (extrapyramidal symptoms) with no specification of the delivery method. Nurses could choose to administer the same dose of medications by "IM" (intramuscular injection) or "p.o." (orally). Additionally, 1 of 8 active sample patients (C10) and 2 of 14 non- sample patients (C9 and D4) had PRN orders for at least two different medications for identical indications, without specific guidance to nursing as to which medication to use. These failures place the nursing staff in a situation that requires them to function beyond the scope of nursing practice. Ambiguous physician orders can result in serious complications from improperly administered PRN medications. (Refer to B125 Part II.)

VI. Ensure that when medications were used which decreased patient participation in treatment they were recognized as chemical restraint, for one of eight active sample patients (C3) and one of fourteen non-sample patients (C13) reviewed for medication usage. Nursing staff administered medications that resulted in the patients missing group therapies and/or sleeping during groups. These medications were being used to control behaviors per nursing notes and interviews. Nursing staff failed to recognize these events as chemical restraint and did not complete seclusion/restraint documentation for the patient. This failure violates a person's right to be free of restrictive measures without justification.
(Refer to B125 Part III.)

VII. Ensure that sensitive patient information was protected from being overheard for 2 non-sample patients, including Patient E8. Patient E8's daughter was informed of the patient's condition, treatment and discharge plans by the attending physician in the Ward E day area with other patients present. The second example occurred when the attending physician was dictating over the phone an admission history while standing in the Ward C day area with 2 non-sample patients standing nearby. These failures to protect patient privacy place patients at risk for confidential information to be disseminated among their peers and can lead to an impediment for continued treatment if patients cannot trust staff to respect their privacy. (Refer to B125, Part IV)




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Based on observation, interview and document review, the Director of Nursing failed to:

I. Ensure that the Master Treatment Plans of 8 of 8 active sample patients (C3, C4, C10, C14, D3, D7, E4 and E6) included nursing interventions that were individualized for patients. Nursing interventions were chosen from a preprinted list (the majority being routine, generic discipline functions) without information added to individualize the plans based on patient needs. The absence of individualized interventions on treatment plans hampers staff's ability to provide individualized care to patients.

Findings include:

A. Review of the master treatment plans of the following 8 sample patients (dates of plans in parentheses): C3 (8/29/11); C4 (8/19/11); C10 (8/22/11); C14 ( 8/27/11); D3 (8/26/11); D7 (8/20/11); E4 (8/8/11 with latest revision on 8/26/11) and E6 (8/24/11 with latest revision on 8/25/11) revealed the following findings:

1. Patients C4, D3, D7, E4 and E6:

For the problem identified as "Depressive Symptoms," nursing interventions included the following generic, role functions for each patient without individualization, other than number of times to be performed:

"Monitor for medication side effects and effectiveness of teaching regarding precautions, benefits, and discharge medication regimen at least __.
Direct and assist patient to groups and activities each shift.
Redirect patient for intrusiveness or inappropriateness with peers, set limits as needed."

2. Patients C3, C10 and C14:

For the problem identified as "Psychotic Symptoms: Delusional Thoughts," nursing interventions included the following generic, role functions for each patient without individualization other than number of times to be performed:
"Reorient to time, place person (sic) whenever delusional symptoms interfere w/ [with] reality contact.
Work together with pt [patient] & team to identify symptoms which are problematic- i.e. Pressured (sic) speech, intrusiveness, grandiose thoughts suspitcions (sic) of others.
Engage pt [patient] in partnership w/ [with] staff agreeing to point out symptoms and bring to patient's attention as these occur.
After agreement is established, help pt. [patient] achieve control of symptoms as they occur through each 1:1 and/or group interaction.
Provide medication education prior to initiation of therapy and as needed during continuation of same at time of each administration.
Monitor and document any factors contributing to disorientation or precipitants to delusions."

3. Patients C4, C10, D3 and E4:

For the problem identified as "Suicide Thoughts/Plan/Attempts," nursing interventions included the following generic, role functions for each patient without individualization other than number of times to be performed:

"Assess patient through 1:1 contact for suicidal ideation and precaution level every shift.
Assist patient in developing relapse and crisis plan, addressing how he/she would handle suicidal ideation after discharge.
Educate patient/family regarding disease process __ times, reinforcing as needed.
Monitor and check for medication as prescribed for ingestion, "cheeking" etc. at each administration.
Provide/maintain safe environment."

4. Patients C3, C4 and D7:

For the problem identified as "Substance Abuse Withdrawal," nursing interventions included the following generic, role function for each patient without individualization other than number of times to be performed:

"Monitor vital signs at least every __ hrs. second and third day of stay and medicate as ordered for symptoms of withdrawal as these appear, at least every __ hrs."

B. Interviews:

1. During interview on 8/31/11 at 1:50p.m., RN 1 verified that the nursing interventions on the treatment plans for Patients C3 and C14 were not individualized based on patient needs.

2. During interview on 9/1/ at 3:40p.m., the Director of Nursing stated that the nursing interventions on the treatment plans were not individualized.

II. Ensure that patients were able to participate in active programming on Unit C. Patients were over-medicated through the use of PRN (as needed) sedating medications for one of four active sample patients (C3), and one of 14 non-sample patients chosen for review of medication usage (C13) on Unit C. Both patients complained that they were unable to participate in unit activities secondary to over sedation. This failure may unnecessarily prolong a patient's hospitalization. (Refer to B125, Part I.)

III. Ensure that medications administered by nursing staff were based on physicians ' orders that included specific parameters for use for 4 of 8 active sample patients (C3, C4, C10 and C14) and for 9 of 14 non-sample patients (C1, C2, C5, C6, C8, C13, C15, C16 and C17) added for medication order review. For these patients, physician orders were written on a PRN (as necessary) basis for "anxiety", "psychosis" or "EPS" (extrapyramidal symptoms) with no specification of the delivery method. Nursing staff accepted these physician orders, and then were able to choose to administer the same dose of medications by "IM" (intramuscular injection) or "p.o." (orally) and failed to document the rationale for the route of administration of the medications.

Additionally, for 1 of 8 active sample patients (C10) and 2 of 14 non-sample patients (C9 and D4), nurses accepted PRN orders for two different medications for the same indication, and chose which to administer without specific physician guidance as to which medication to use. These failures place the nursing staff in a situation that requires them to function beyond the scope of nursing practice. Ambiguous physician orders can result in serious complications from improperly administered PRN medications. (Refer to B125 Part II.)

III. Ensure that when medications were used which decreased patient participation in treatment they were recognized as chemical restraint, for one of eight active sample patients (C3) and one of fourteen non-sample patients (C13) reviewed for medication usage. Nursing staff administered medications that resulted in the patients missing group therapies and/or sleeping during groups. These medications were being used to control behaviors per nursing notes and interviews. Nursing staff failed to recognize these events as chemical restraint and did not complete seclusion/restraint documentation for the patient. This failure violates a person's right to be free of restrictive measures without justification.. (Refer to B125 Part III.)

IV. Ensure that sensitive patient information was protected from being overheard for 1 of 8 active sample patients (E8). Patient E8's daughter was informed of the patient's condition, treatment and discharge plans by the attending physician and a RN in the Ward E day area with other patients present. In addition, staff were observed discussing patient information with each other and on the telephones at open nursing stations on all three wards. Patients were observed walking and sitting in the immediate areas within hearing distance of the nursing stations. These failures to protect patient privacy place patients at risk for confidential information to be disseminated among their peers and can lead to an impediment for continued treatment if patients cannot trust staff to respect their privacy.

Findings include:

Observation of the Ward D (Senior Behavioral) on 8/31/11 at 11:15a.m. revealed MD 1 and an RN (name unknown) talking to the daughter of non-sample Patient E8 about the medications and treatment of that patient at the nursing station. This conversation took place with several patients sitting in the immediate area. Staff were observed discussing patient information with each other and on the telephones at open nursing stations on all three wards. Patients were observed walking and sitting in the immediate areas within hearing distance of the nursing stations.

V. Ensure physical safety for patients. An unlocked open hall bathroom on Ward C (Adult Psychiatry) contained an open bathtub. This open tub on an acute unit with ambulatory patients with psychiatric/behavioral problem poses a safety risk for all patients.

Findings include:

A. During rounds with RN1 on 8/31/11 at 1:30p.m. on Ward C (Adult Psychiatry), observation revealed an unlocked bathroom with an open bathtub off of the hall by Patient Room #19. When asked about this observation, RN1 stated, "We make regular rounds and we could hear if the water was running."

B. During rounds of this ward with the Director of Nursing on 8/31/11 at 3:30p.m., the DON stated that this tub could be a safety hazard.






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