HospitalInspections.org

Based on observation, interview and document review, it was determined that the Governing Body failed to exercise its oversight responsibilities in the operation of the hospital in that it:

1. failed to provide a safe setting for patients ( refer to Tag A144),

2. failed to provide personal privacy (refer to Tag A143),

3. failed to assure patients were free from physical restraint (refer to tag A154),

4. failed to ensure that the nutritional needs of patients were met (refer to Tag A392),

5. failed to ensure that staff assess the effectiveness of medications administered to patients (refer to Tag A395),

6. failed to ensure that patients were consistently assessed by staff for placement in appropriate therapy groups to meet the therapeutic needs of patients (refer to Tag A395),

7. failed to ensure that a current care plan was maintained tat addressed the needs of patients (refer to Tag A396), and

8. failed o administer medications as ordered by the physician (refer to Tag A405).

The failed practices had the potential to affect all patients admitted to this hospital.

Based on observation, interview and document review, it was determined the facility

1. failed to provide a safe setting for patients (refer to Tag A144),

2. failed to provide personal privacy (refer to Tag A143).

The failed practices affected Patients #1-#4 and had the potential to affect all patients admitted to the Geriatric Psychiatric Unit.

Based on observation, clinical record review and interview, it was determined that the facility failed to promote the right of patients to privacy in that patients (Pts) #1-#3 were placed on bed mattresses on the floor and out of their room environment at night; Pt. #4 was placed in a Geri chair with feet elevated and pushed against a table in the Day Area. The failed practice did not provide an emotionally safe environment and assure the privacy and dignity of Pts #1-#4 and had the potential to affect all patients admitted to the Unit. (See Tag A-144)

Based on observation, clinical record review and interview, it was determined that the facility failed to assure care was provided in a safe setting and, that privacy and dignity were maintained for four (#1-#4) of 10 Pts (#1-#10). Patients #1 - #3 were placed on mattresses on the floor in areas not designated as patient rooms. These patients were exposed to potential infection from floor contamination and did not have access to a call light system to summon help if needed. Patient #4 was placed in a Geri chair with feet elevated and pushed against a table in the common activity area. The emotional and physical safety needs of Pts #1-#4 could not be assured based on facility actions. The failed practice affected Pts #1- #4 and had the potential to affect all patients on the Unit. The findings follow

A. Patient (Pt) #1 was admitted on 03/14/14. The admission diagnosis was depression with agitation. Observation at 2310 PM on 03/24/14, revealed that Pt #1 was asleep on a bed mattress that was directly on the floor in the common activity area. A wedge covered in vinyl was placed directly on the floor without a barrier under the head of the mattress. The activity area was a carpeted open area and not designated as a patient room.

1) In an interview on 03/25/14, at 0010 AM, RN #1, RN #2 and LPN #1 stated "He has an order to be on line-of-sight observation because he pulled out his feeding tube. A "Line of Sight" order was always a mattress on the floor."

2) Observation at 0030 AM on 03/25/14, revealed that Pt #1 moved his legs off the side of the mattress that was on the floor. Pt #1 was assisted to stand from the mattress on the floor by two staff members who lifted him by placing their arms under his arms. Patient #1 was ambulated to his room and to the restroom. After toileting, he was ambulated to a Geri chair assisted by two staff members. In an interview on 03/26/14, at 1000 AM, Registered Nurse (RN) #1 stated "he is ambulatory with the assistance of two staff".

3) Adult Admission Assessment on 03/14/14, revealed a Morse Fall Risk score of 35, "Fall Assess Nursing Judgment" was documented as "High Risk". The care plan included "risk for falls" with the following interventions: assist with ADLs (activities of daily living), assist with meals, assistance with feeding, bed in low, locked position, encourage use of nonskid footwear, leave door open and monitor for incontinence every two hours. Move patient close to Nursing Station, offer assistance with toileting, orient/reorient to person, place, environment, report any deviations from prior assessment, safety education. The care plan did not include an intervention to place the bed mattress on the floor to prevent falls.

4) Review of physician orders revealed no order to place the patient mattress on the floor. A physician order was noted for "Line of sight as Nurses Station" on 03/21/14 at 1735. On 03/26/14 a Policy for line-of-sight observation was requested from Clinical Manager #1 and she stated there was not a specific policy.

5) Review of Nursing Progress Note for 03/15/14 at 1828 revealed, "Remains at nurse's station with staff in direct contact with bilateral mittens in place". A Nursing Progress Note for 03/21/14 at 1735 stated "Order to place mittens on patient and remain on line of sight at nurse's desk." Nursing progress note for 03/25/14 at 0406 stated "Patient has been restless at times tonight, no aggression. Walked several times by staff to bathroom-takes two to ambulate patient shuffling unsteady gait. Patient sleeping on mattress in Day Area-line of sight for safety. Patient has not attempted to pull at peg tube."



B. Pt #2 was admitted on 03/22/14. The admission diagnosis was Dementia with depression and anxiety. Observation on 03/24/14, at 2315 PM, revealed that Pt #2 was on a bed mattress on the floor of the "Admission Room" which was across from the nursing station. That room was not a patient room.

1) RN #1 stated at the time of observation that the patient was not steady ambulating and "she wanders and tries to go to the bathroom in the hallway. Her room is way on the other end. She can tell us when she needs to go to the bathroom, but is confused and combative at times." On 03/26/14, at 1000 AM, RN #1 was interviewed and stated Pt #2 is
"ambulatory with assistance of one, but unsteady and uses the wheelchair for distance".

2) The Interdisciplinary Care Plan, reviewed 03/24/14, listed "risk for falls" with a goal of "to be free of falls or injuries". The interventions stated "Assist with ADLs, assistive devices, bed in low, locked position, encourage use of nonskid footwear, fall prevention protocol, and family/caregiver education. Leave door open, offer assistance with toileting. Orient/reorient to person, place and environment. Report any deviations from prior assessment. Safety education, yellow tag on patient's door." The care plan did not include an intervention to place the bed mattress on the floor to prevent falls.

3) Review of a Nursing Progress Note on 03/26/14, for 03/25/14 at 0418 AM, revealed: "Pt. assisted by nurse up to w/c (wheelchair) and to bathroom, unsteady gait, confused and impulsive, no agitation and cooperative with care. A Nursing Progress Note entry for 03/26/14, at 0124 AM, revealed "Patient observed standing in doorway looking out-holding onto door. Staff ran and caught patient before she fell-patient refused to walk or even lift legs after this and staff had to support most of her weight until another staff member brought a chair. Patient was taken to bathroom."

4) Review of physician orders revealed no order to place the patient on a mattress on the floor.



C. Patient #3 was admitted on 03/21/14. The admission diagnosis was Alzheimer's Dementia with anxiety and agitation. Observation on 03/24/14, at 2315 PM, revealed Pt #3 was on a bed mattress on the floor of the Seclusion Room. The Seclusion Room door was open. A black pad was observed beside the mattress on the floor.

1) RN #1 stated, at the time of observation, that "we put a pad on the floor because the floor is rough and he would scratch his hands".

2) Review of a Nursing Progress Note for 03/25/14, at 0415 AM, revealed "patient resting on mattress in Seclusion Room with door open. Patient is non-ambulatory confused not able to follow directions-impulsive. Patient stood by self several times earlier in shift when in Day Area - unsteady, staff had to catch patient and redirect him. Placed on mattress with camera on for safety. In an interview with RN #1 on 03/26/14, at 1000 AM, she stated that Pt. #3 was chairfast and non-ambulatory.

3) Review of the plan of care revealed no intervention to place the bed mattress on the floor. The plan of care included "Assist with ADLs, bed in low locked position, fall prevention protocol, monitor for incontinence every two hours, move patient close to nursing station, offer assistance with toileting, orient/reorient to person, place, environment, orthotic/splint training and yellow tag on patient's door." Review of physician orders 03/25/14, revealed no physician order to place the patient on a mattress on the floor.



D. Patient #4 was admitted on 03/04/14. Admission diagnosis was progressive Alzheimer's dementia with hallucinations and agitation. Observation at 2310 PM on 03/24/14, revealed that Patient #4 was in a geriatric chair, with a Velcro strap across his lap, chair feet were elevated and the chair was pushed up to a table. Patient #4 was asleep, leaning to the left in the chair. RN #1 stated "he can ambulate and was last night, but he is unsteady tonight. We have them sit up while they are restless. If patients are agitated, we put them in a Geri chair until they calm down".

1) On 03/25/14, at 0020 AM, Pt #4 was ambulated to his room by two staff members.

2) Review of the Nursing Progress Note on 03/26/14, for 03/25/14 at 0422 AM, revealed "resting in bed, with side rails up times two. Taken to bathroom earlier in shift-restless combative-confused. Incontinent of urine and voided in toilet. Taken to bed when noted to be sleeping in Day Area in chair." A Nursing progress note for 03/25/14, at 2233 PM revealed "up wandering on Unit-confused pleasant sitting at times with co-patients. Disoriented to place and situation." On 03/25/14, at 1149 PM, Nursing Progress Note revealed "staff has been sitting with patient in Day Area - he has been helped to bed on three different occasions, patient has gotten up and began wandering. Staff ambulated around Unit with patient. Patient ate two bowls of cream-of-wheat, a banana, glass of milk and peanut butter."

3) A Nurse Progress Note was noted for March 25, 2014, at 1146 PM, that stated "Up wandering on Unit into other's rooms-combative when redirected-attempts to punch staff takes three staff members to escort patient. Confused looking for his wife-rambling speech. Staff one-on-one with patient hallucinating seeing people in the walls. LPN sitting with patient reading a book to him. Restless-not able to focus (doctor named) notified with orders received."

4) A Nursing Progress Note for 03/26/14, at 0111 AM, stated "Patient remains confused and impulsive-attempting to doze in chair next to staff in Day Area. Patient helped into bed across from nursing desk in Admit Room under close observation from staff to prevent falls and dangerous wandering behavior for tonight."

5) Review of the plan of care and physician orders on 03/26/14, revealed there was no intervention or physician order for placement of Pt. #4 in a Geri chair with feet elevated for fall prevention. The plan of care included "Assist with ADLs, bed in low locked position, fall prevention protocol, monitor for incontinence every two hours, move patient close to nursing station, offer assistance with toileting, orient/reorient to person, place, environment, orthotic/splint training and yellow tag on patient's door."



E. Review of the facility policy "Falls Prevention Program" with a revision date of 05/27/11, revealed "Preventive measures: If it is determined that a patient is at moderate risk for falls the following indicators will be used: A yellow tag will be placed on the patient's door, yellow skid-proof socks will be placed on the patient, a yellow fall alert sticker is to be placed on the chart and a yellow bracelet will be placed on the patient. A bed exit system will be used on patients identified by nursing to be high risk for falls when appropriate. The CareView System will be offered to patients considered to be moderate or high risk on the Morse fall score."



F. The findings were confirmed by interview on 03/26/14, at 1230 PM, with Clinical Manager #1.

Based on clinical record review and interview, it was determined that the facility failed to administer two nutritional supplements as ordered by the physician for 5 days for 1(#3) of 10 (#1-#10) clinical records reviewed. One supplement was ordered to be administered three times daily and one was to be administered twice daily. The Nursing staff failed to administer the supplement as ordered and failed to notify the physician.

The failed practice did not assure that the nutritional needs of Pt. #3 would be met and had the potential to affect any patient admitted to the Unit.

The findings were:

A. Review of the clinical record For Pt #3 on 03/26/14, revealed physician orders on 03/21/14, at 1920 PM, for the supplements "Resource 2.0/2 oz (ounces) P.O. (by mouth) t.i.d. (three times per day) and Prostat 30 ml (milliliters) P.O. bid (twice per day).

1) Director #1 and Clinical Manager #1 stated at the time of clinical record review on 03/26/14, at 1200 PM, that the physician ordered supplements were included in the "intake and output".

2) Dietitian #1 was interviewed on 03/26/14, at 1210 PM, regarding the supplements ordered. Dietitian #1 stated she observed Pt #3 and noted Pt. #3 had difficulty with the meal. Dietitian #1 reviewed the chart and discovered the supplements ordered were not carried by the facility. Upon investigation, Dietitian #1 noted that the order for the supplements had been printing out and in the computer since 03/21/14, but not sent from the Dietary Department. Dietitian #1 documented on a "Communication Sheet" on 03/25/14, at 0745 AM, "Recommend Ensure Pudding tid and thrive bid. On 03/25/14 at 1600 Dietician #1 documented "Nutrition supplements ordered are not carried in house: Prostat 30 ml bid. Recommend change to 2 pkts (packets) Propass bid to mix with nectar thick liquids/food. Resource 2.0, 6 ml- Recommend change to Thrive bid".

3) Physician order noted on 03/26/14, for "Propass (two) packets twice daily mix with liquids, thrive 1 P.O. twice daily. Discontinue Prostat and Resource."



B. Patient #3 did not receive the two supplements as ordered by the physician for five days. The clinical record did not include evidence the physician was informed the supplements ordered were not available.



C. This was confirmed at the time of interview with Dietitian #1 and Clinical Manager #1.

Based on clinical record review and interview, it was determined that the facility failed to have a policy or procedure that established parameters or criteria to determine the patients that were to attend specific therapy Groups. The failed practice did not allow clinical staff to make an assessment based on established criteria for Group therapy placement. The failed practice affected the patient census of 15 and had the potential to affect all patients admitted to the Unit.

The findings were:

A. On 03/26/14 clinical record review revealed no physician orders for the type, frequency of participation or determination of Groups the patient was to attend while on the Unit.

B. On 03/26/14, at 0930 AM, Physician #1 was interviewed and stated "Group participation is part of what we do on the Unit, it is the same. Everyone should participate".

C. Clinical Manager #1 was interviewed on 03/26/14, and stated "Everyone gets the same Group Therapy offered". Review of the "Group" Schedule revealed the following Groups offered Monday thru Friday: Exercise, Nursing, Process Group and Socialization, Leisure Group and Relaxation group. Saturday and Sunday: Exercise, Nursing, Movie and Relaxation Group.

D. RN #2 stated by interview on 03/26/14, that patients were identified at the beginning of the day shift each day to determine if they would attend "Front Group" or "Back Group". The placement was assigned by the RN and the more aggressive and disruptive patients were segregated to the Back Group.

E. A copy of a policy or procedure for determining Group placement was requested on 03/26/14. Clinical Nurse Manager #1 and Director #1 stated there was no written policy or process for determining which patients attend "Front" or "Back" Groups on 03/26/14 at 1130.



Based on review of policies and procedures, review of clinical records and interview, it was determined that the Emergency Room staff failed to assess patients to determine effectiveness of medications administered in 7 (#3,#4,#10, #12-#15) of 15 (#1-#15) records reviewed.

The failed practice did not assure patients' symptoms were improved or whether further intervention was needed. The failed practice had the potential to affect all patients in the Emergency Room.

Findings:

A. Review of Patient #3's clinical record revealed Morphine 10 mg (milligrams) was administered on 03/03/14 at 1317 PM. There was no evidence that Patient #3 was assessed to determine the effectiveness of the medication given.

B. Review of Patient #4's clinical record revealed that Hydromorphone 1 mg and Ondansetron 4 mg wwere administered on 03/06/14 at 1831 PM. There was no evidence that Patient #4's response to the medication was assessed.

C. Review of Patient #10's clinical record revealed Donnatal/Lidocaine/Gaviscon suspension 30 ml was administered on 03/11/14 at 1757 PM. There was no evidence that Patient #10's response to the medication was assessed.

D. Review of Patient #12's clinical record revealed Hydromorphone 1 mg was administered at 0907 AM and 1154 AM, and Ondansetron 4 mg was administered at 0907 AM and 1154 AM on 03/12/14. There was no evidence that Patient #12's response to the medications was assessed.

E. Review of Patient #13's clinical record revealed Ondansetron 4 mg was administered at 1716 PM on 03/12/14. There was no evidence that Patient #13's response to the medication was assessed.

F. Review of Patient #14's clinical record revealed Ketorolac 30 mg was administered on 03/13/14 at 0710 AM. There was no evidence that Patient #14's response to the medication was assessed.

G. Review of Patient #15's clinical record revealed Hydromorphone 1 mg was administered on 03/13/14 at 0125 AM and 0307 AM. Ondansetron 4 mg was administered on 03/13/14 at 0125 AM. There was no evidence that Patient #15's response to the medications was assessed.

H. Review of Policy, "Pain Management" presented by the Safety Officer on 03/26/14, revealed reassessments, pain intensity and relief will be reassessed when clinically indicated and documented by the end of the shift, with pharmacologic or non-pharmacologic intervention. Reassessment indicating pain unrelieved or more intense.

I. Review of Policy, "Patient Assessment/Reassessment" presented by the Safety Officer on 03/26/14, revealed Reassessment: reassessment is a component of the patient plan of care and is conducted at key determinant events as well as throughout the care continuum. Reassessment is the evaluation of patient response to treatment and care in order to determine the appropriateness and effectiveness of care decisions.

J. Findings were verified with the Emergency Department Director during interview 03/26/14, at 1010 AM.

Based on observation, clinical record review and interview, it was determined that the facility failed to assure the plan of care for 4 Patients (Pts) (#1- #4) of 10 (#1-#10) was current and based on the assessed needs of the patients. Failure to have a plan of care that is based on assessment of the patient did not assure needs would be identified and addressed accordingly. The failed practice affected Pts #1-#4 and had the potential to affect all patients on the Unit at the time of the survey.

The findings were:

A. Patient (Pt) #1 was admitted on 03/14/14. The admission diagnosis was depression with agitation. Observation at 2310 PM on 03/24/14, revealed that Pt #1 was asleep on a bed mattress that was directly placed on the floor in the common activity area. A wedge was observed on the floor under the head of the mattress.

1) In an interview on 03/25/14, at 0010 AM, RN #1, RN #2 and LPN #1 stated "He has an order to be on line-of-sight observation because he pulled out his feeding tube. A "Line-of-Sight" order is always a mattress on the floor."

2) At 0030 AM on 03/25/14, Pt #1 was observed moving his legs off the side of the mattress that was on the floor. Pt #1 was assisted to stand from the mattress on the floor by two staff members who lifted him by placing their arms under his arms. Patient #1 was ambulated to his room and to the restroom. After toileting, he was ambulated to a Geri chair assisted by two staff members.

3) Adult Admission Assessment on 03/14/14, revealed a Morse Fall Risk score of 35, "Fall Assess Nursing Judgment" was documented as "High Risk". The care plan included "risk for falls" with the following interventions: assist with ADLs (activities of daily living), assist with meals, assistance with feeding, bed in low, locked position, encourage use of nonskid footwear, leave door open, and monitor for incontinence every two hours. Move patient close to Nursing Station, offer assistance with toileting, orient/reorient to person, place, environment, report any deviations from prior assessment, safety education. The care plan did not include an intervention to place the bed mattress on the floor to prevent falls.

4) Review of physician orders revealed no order to place the patient mattress on the floor. A physician order was noted for "Line of sight as Nurses Station" on 03/21/14 at 1735.

5) Review of Nursing Progress Note for 03/15/14, at 1828 PM, revealed, "Remains at nurse's station with staff in direct contact with bilateral mittens in place". A Nursing Progress Note for 03/21/14, at 1735 PM, stated "Order to place mittens on patient and remain on line of sight at nurse's desk." Nursing Progress Note for 03/25/14, at 0406 AM, stated "Patient has been restless at times tonight, no aggression. Walked several times by staff to bathroom-takes two to ambulate patient shuffling unsteady gait. Patient sleeping on mattress in Day Area - line of sight for safety. Patient has not attempted to pull at peg tube."



B. Pt #2 was admitted on 03/22/14. The admission diagnosis was Dementia with depression and anxiety. Observation on 03/24/14, at 2315 PM, revealed Pt #2 was on a bed mattress on the floor of the "Admission Room" which was across from the nursing station. That room was not a patient room.

1) RN #1 stated at the time of observation the patient was not steady ambulating and "she wanders and tries to go to the bathroom in the hallway. Her room is way on the other end. She can tell us when she needs to go to the bathroom, but is confused and combative at times."

2) The Interdisciplinary Care Plan, reviewed 03/24/14, listed "risk for falls" with a goal of "to be free of falls or injuries". The interventions stated "Assist with ADLs, assistive devices, bed in low, locked position, encourage use of nonskid footwear, fall prevention protocol, and family/caregiver education. Leave door open, offer assistance with toileting. Orient/reorient to person, place and environment. Report any deviations from prior assessment. Safety education, yellow tag on patient's door." The care plan did not include an intervention to place the bed mattress on the floor to prevent falls.

3) Review of a Nursing Progress Note on 03/26/14, for 03/25/14 at 0418 AM, revealed: "Pt. assisted by nurse up to w/c (wheelchair) and to bathroom, unsteady gait, confused and impulsive, no agitation and cooperative with care. A Nursing Progress Note entry for 03/26/14, at 0124 AM, revealed "Patient observed standing in doorway looking out-holding onto door. Staff ran and caught patient before she fell-patient refused to walk or even lift legs after this and staff had to support most of her weight until another staff member brought a chair. Patient was taken to bathroom."

4) Review of physician orders revealed no order to place the patient on a mattress on the floor.



C. Pt #3 was admitted on 03/21/14. The admission diagnosis was Alzheimer's Dementia with anxiety and agitation. Observation on 03/24/14, at 2315 PM, revealed Pt #3 was on a bed mattress on the floor of the Seclusion Room. The Seclusion Room door was open. A black pad was observed beside the mattress on the floor.

1) RN #1 stated at the time of observation that "we put a pad on the floor because the floor is rough and he would scratch his hands".

2) Review of a Nursing Progress Note for 03/25/14, at 0415 AM, revealed "patient resting on mattress in Seclusion Room with door open. Patient is non-ambulatory confused not able to follow directions-impulsive. Patient stood by self several times earlier in shift when in Day Area - unsteady, staff had to catch patient and redirect him. Placed on mattress with camera on for safety.

3) Review of the plan of care 03/26/14, revealed that there was no intervention to place the patient's bed mattress on the floor. The plan of care included "Assist with ADLs, bed in low locked position, fall prevention protocol, monitor for incontinence every two hours, move patient close to nursing station, offer assistance with toileting, orient/reorient to person, place, environment, orthotic/splint training and yellow tag on patient's door." Review of physician orders revealed no order to place the patient on a mattress on the floor.



D. Patient #4 was admitted on 03/04/14. Admission diagnosis was progressive Alzheimer's dementia with hallucinations and agitation. Observation at 2310 PM on 03/24/14, revealed that Patient #4 was in a geriatric chair, with a Velcro strap across his lap, chair feet were elevated and the chair was pushed up to a table. Patient #4 was asleep, leaning to the left in the chair. RN #1 stated "he can ambulate and was last night, but he is unsteady tonight. We have them sit up while they are restless. If patients are agitated, we put them in a Geri chair until they calm down."

1) On 03/25/14, at 0020 AM, Pt #4 was ambulated to his room by two staff members.

2) Review of the Nursing Progress Note on 03/26/14, for 03/25/14 at 0422 AM, revealed "resting in bed, with side rails up times two. Taken to bathroom earlier in shift-restless combative-confused. Incontinent of urine and voided in toilet. Taken to bed when noted to be sleeping in day area in chair." A Nursing Progress Note for 03/25/14, at 2233 PM, revealed "up wandering on Unit-confused pleasant sitting at times with co-patients. Disoriented to place and situation." On 03/25/14 at 1149 PM Nursing Progress Note revealed "staff has been sitting with patient in Day Area - he has been helped to bed on three difference occasions, patient has gotten up and began wandering. Staff ambulated around unit with patient. Patient has ate two bowls of cream-of-wheat, a banana, glass of milk and peanut butter."

3) A Nurse Progress Note was noted for March 25, 2014, at 1146 AM, that stated "Up wandering on Unit into other's rooms-combative when redirected-attempts to punch staff takes three staff members to escort patient. Confused looking for his wife-rambling speech. Staff one-on-one with patient hallucinating seeing people in the walls. LPN sitting with patient reading a book to him. Restless-not able to focus (doctor named) notified with orders received."

4) A Nursing Progress Note for 03/26/14, at 0111 AM, stated "Patient remains confused and impulsive-attempting to doze in chair next to staff in Day Area. Patient helped into bed across from nursing desk in Admit Room under close observation from staff to prevent falls and dangerous wandering behavior for tonight."

5) Review of the plan of care and physician orders on 03/26/14, revealed there was no intervention or physician order for placement of Pt. #4 in a Geri chair with feet elevated for fall prevention/agitation. The plan of care included "Assist with ADLs, bed in low locked position, fall prevention protocol, monitor for incontinence every two hours, move patient close to nursing station, offer assistance with toileting, orient/reorient to person, place, environment, orthotic/splint training and yellow tag on patient's door."



E. Review of the facility policy "Falls Prevention Program" with a revision date of 05/27/11, revealed "Preventive measures: If it is determined that a patient is at moderate risk for falls the following indicators will be used: A yellow tag will be placed on the patient's door, yellow skid-proof socks will be placed on the patient, a yellow fall alert sticker is to be placed on the chart and a yellow bracelet will be placed on the patient. A bed exit system will be used on patients identified by nursing to be high risk for falls when appropriate. The CareView System will be offered to patients considered to be moderate or high risk on the Morse fall score." The policy did not include an intervention to place the patient on a mattress on the floor.


F. The findings were confirmed by interview 03/26/14, at 1230 PM, with Clinical Manager #1.

Based on policy and procedure review, clinical record review and interview, it was determined that the Facility failed to administer medication as ordered by the physician for 2(#7 and #8) of 10 (#1-#10) clinical records reviewed. The medication was not administered as the physician had ordered, therefore the therapeutic effect of the medication could not be assured. The failed practice affected Patients (Pts) #7 and #8 and had the potential to affect all patients admitted to the Unit.

Findings:

A. Clinical record review on 03/26/14, revealed Pt #7 was admitted 03/19/14. A physician order was noted on 03/20/14, for "Lidocaine Patches daily for 12 hours then remove during night time."

1) Review of the Medication Administration Record revealed that the Lidocaine Patches were not administered 03/22/14, and 03/23/14, to Pt #7. The clinical record did not include evidence the physician was notified the medication was not administered.

2) The findings were confirmed by Clinical Manager #1 at the time of clinical record review.


B. Clinical record review on 03/26/14, revealed Pt #8 was admitted on 03/18/14, with a diagnosis of Paranoid Schizophrenia. A physician order was noted on admission for "Lurasidone (Latuda) 80 mg oral tablet at bedtime".

1) Review of the Medication Administration record revealed that the antipsychotic medication, Lurasidone, was not administered to Pt #8 as ordered by the physician. Pt. #8 did not receive Lurasidone from 03/18/14 - 03/25/14, a period of eight days.

2) Review of the physician "Daily Psychiatric Progress Record" for 03/25/14 at 1100 AM, revealed under "Impression/Plan" the note "Paranoid Schizophrenia. Needs Latuda!" A note for 03/26/14, at 0830 AM, stated "Paranoid Schizophrenia, Latuda 80 mg/d".

3) Clinical Nurse Manager #1 stated by interview at the time of record review on 03/26/14, the Pharmacy would notify the physician for clarification if the medication was not formulary or if they could not get the medicine.

4) Review of the "Communication Sheet" revealed documentation for 03/18/14, at 2200 PM, that stated "Pharmacy said Latuda is non-formulary. I called (Facility named) they are going to leave a note for day shift to see if we can get it from them, otherwise we will need to do something else." This was signed by RN#1.

5) In an interview with Counselor #1 on 03/26/14, at 1130 AM, he stated that he was asked by the physician to pick up samples of Pt #8 medicine on 03/25/14. Counselor #1 stated he went to prior treatment Facility of Pt #8 and picked up the samples.

6) Pharmacist #1 was interviewed on 03/26/14, at 1215 PM, and stated "if the medication is non-formulary we change it to the medication we have. The Latuda is not really formulary and was determined by the Pharmacist to be non-critical, so that means it was put in as a clarification order for the physician. We try to get the medication either from the patient's home or the Facility where they came from."

7) Review of the following policies provided by Pharmacist #1 on 03/26/14, revealed:

a) "Hospital Formulary" with a review/revision date 01/28/14. Item 1.G.1 stated "The Formulary authorizes: that another generically equivalent product may be administered, unless the prescribing physician specifically asks that the order be dispensed as written. "Item II" Non-formulary Drugs", stated "A quantity sufficient to meet the needs of the patient will be purchased. The total amount will be charged to the patient. Non-formulary drugs will not be refunded. A delay of 48-72 hours may occur when a non-formulary drug is requested."

b) "Home Medications for Patient Use at (Facility named)" with a review/revision date of 01/28/14, the "Policy Elaboration" stated "there are times when it is necessary for a patient to use their own medications. A process must be in place to assure the safety of the patient for proper storage, identification and administration of these home medications." The procedure stated: "An order is written for a medication that is non-formulary or unavailable. Pharmacist will determine if it is an urgent or non-urgent medication. If it is determined that is an urgent medication and patient harm would result by patient not receiving the medication, Pharmacist will try to obtain the medication. If either the patient is willing or the physician desires that the patient's own meds be used, an order must be obtained from the physician to authorize use of a patient's own meds." "If it is determined that the medication is non-urgent, the Pharmacy Department will take the following steps: The Pharmacist will profile onto patient's MAR as a Clarification order, type "waiting confirmation to see if patient can bring in their own med, Nursing will communicate with patient to see if they are willing to bring the medication in from home."

C) The findings were confirmed by Clinical Manager #1 on 03/26/14, at 1230 PM.