HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure that all licensed nursing staff followed policies and procedures when performing nursing services, including all clinical interventions and the administration of medications and blood components.

Failure to adhere to hospital policies while performing nursing services, including all clinical interventions and the administration of medications and blood components places patients at risk for harm including infection, ineffective treatment, and death.

Findings included:

1. The hospital failed to provide patients with appropriate and timely medical care during their hospitalization.

Cross-reference Tag A-395

2. The hospital failed to provide patients with the necessary nutritional assessments and dietary consultations during their hospitalization

Cross-reference Tag A-398

3. The hospital failed to ensure that staff recorded the nutritional intake assessment following each meal.

Cross-reference Tag A-398

4. The hospital failed to assess patients for allergies prior to administering medications.

Cross-reference Tag A-405

Due to the scope and severity of these deficiencies, the Condition of Participation at 42 CFR 482.23 Nursing Services was NOT MET.
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Based on interview, record review, and review of policies and procedures, the hospital staff failed to provide patients with the appropriate medical care during their hospitalization, as demonstrated by 2 of 4 records reviewed (Patient #1501 and #1505).

Failure to provide patients with appropriate and timely medical care can result in inconsistent or delayed treatment of patient needs and may lead to patient harm or death.

Findings included:

1. Document review of the hospital's policy titled, "Plan for Provision of Care - Scope of Services," policy number 1000.0, revised 06/21, showed that the following:

a. If emergency medical care is needed, on-site medical and nursing staff will treat the patient within scope and transfer to local medical/surgical facilities when medical stabilization is required.

b. The Pre-Admission Assessment and Nursing Assessment identifies any medical problems and/or interventions which need to be addressed during the hospital stay.

2. Document review of the hospital's policy titled, "Interdisciplinary Patient Centered Care Planning," policy number 1000.81, revised 08/20, showed the following would be cause for conducting a review of the patient's treatment plan and developing a revision including goals and interventions:

a. A new impairment/problem or significant information about an existing impairment is identified.

b. A major change occurs in the patient's clinical condition.

Patient #1501

4. On 07/12/21 at 10:30 AM, Investigator #15, and a Registered Nurse (RN) (Staff #1507), reviewed the medical record for Patient #1501, a 64-year-old male, who was admitted on 05/26/21 for Grave Disability. The Patient had a reported past psychiatric diagnosis of Schizoaffective Disorder, reported a weight loss of approximately 50 pounds in the previous 6 months, and presented as disorganized, malodorous, and cachectic (weakness and wasting of the body due to severe chronic illness). The Patient had been hospitalized in January of 2021 for Grave Disability and Failure to Thrive (FTT). The record review showed the following:

a. On 05/26/21 at 11:58 AM, the Medical Provider initiated a written Physicians Order for a Dietary Consult for "severe failure to thrive and weight loss." On 05/26/21 at 6:00 PM, staff documented that the order was "faxed" to the Dietary Service staff.

b. On the Patient's Individual Medical Treatment Plan for the identified problem of "poor intake," dated 05/26/21, nursing staff documented an intervention for a Dietary Consult. Investigator #15 found no evidence of documentation in the Patient's Treatment Plan or Weekly Updates regarding the Dietary Consultation.

c. On 06/03/21 at 3:40 PM, the Medical Provider initiated a Physicians Order for a Dietary Consult for "low weight, Body Mass Index (BMI) 15." On 06/12/21 at 8:09 AM, (9 days after the order was initiated), staff documented that the order was "faxed" to the Dietary Service staff.

d. Investigator #15 found no evidence of a Dietary/Nutritional Consult for Patient #1501 between 05/26/21 and 06/13/21.

e. Investigator #15's review of the Daily Nursing Progress Notes for Patient #1501 between 05/26/21 and 06/17/21 found that nursing staff documented no oral intake for 44 of 66 meals.

f. On 06/14/21 at 3:29 PM, a Registered Dietitian (RD), conducted an initial Nutrition Assessment for Patient #1501, 19 days after the Patient was admitted to the hospital. The Nutrition Assessment dated 06/14/21 showed the following:

i. History of 50-pound weight loss within past 6 months.

ii. Severe fat loss (observed in Patient's cheeks and mid-axillary).

iii. Severe muscle wasting (observed in Patient's temples, clavicles, shoulders, thighs, patellar, calves and hands).

iv. Very high nutrition risk and very high risk of re-feeding syndrome (defined as potentially fatal shifts in fluids and electrolytes that may occur in malnourished).

v. Recommendations included: diet education, provide patient meals in room, Thiamine supplement, and monitoring of weight and daily oral intake and output. Labs ordered included Phosphate, Magnesium and Potassium. Registered Dietitian to follow-up in 1-3 days.

f. On 06/17/21 at 3:17 PM, a Registered Dietitian (RD), conducted a follow-up Assessment for Patient #150. The Nutrition Assessment dated 06/17/21 showed the following:

i. The RD documented that the patient requested Raisin Bran with milk, Special K with strawberries, bacon, and whole wheat toast. Per nursing staff, the Patient is drinking 3-4 Ensures each day and eating granola bars and graham crackers.

ii. Continue to monitor Patient's weight, labs, blood glucose and tolerance of oral intake.

iii. RD to follow-up in 1-3 days.

g. Investigator #15's review of the medical record for Patient #1501 found five Medical Consult Notes. Only one Medical Consult Note, dated 06/01/21 (misdated), addressed the Patient's Failure to Thrive, and referenced the Medical Providers discussion with the RD after the 06/14/21 Initial Nutrition Assessment. The Medical Provider documented the recommendation to start Patient #1501 on Thiamine to mitigate re-feeding.

5. On 07/12/21 at 1:25 PM, during an interview with Investigator #15 and Investigator #12, a Medical Provider (MD) (Staff #1501), stated that an order for a Dietary/Nutritional Consult is based on the provider's clinical judgement. Staff #1501 stated that he didn't believe there was an automatic trigger for a Dietary Consult, but he would order a consult if a patient's BMI was under 20, or 15. Staff #1501 stated that he could not remember Patient #1501's condition upon his admission on 05/26/21, but found the patient to be "treatment resistant, with severe depression." Staff #1501 reported that Patient #1501 "laid in bed all day and they couldn't force him to eat, walk or accept medical treatment."

Staff #1501 reported that he did not remember his Physicians Order dated 05/26/21, requesting a Dietary Consult for Severe Failure to Thrive and Weight Loss. The Medical Provider stated that "Dietary can do the least, they can't help."

6. On 07/13/21 at 8:00 AM, during an interview with Investigator #15, a Registered Dietitian (RD) (Staff #1505), reported that Dietary Services received the faxed referral for Patient #1501's Dietary Consult on Saturday, 06/12/21. Staff #1505 stated that she assessed Patient #1501 on 06/14/21. The RD stated that Patient #1501 "was the most severe case of wasting ever seen. The patient was severely malnourished." Staff #1505 reported that after the assessment for Patient #1501, she spoke with the Medical Provider regarding her observations.

7. Investigator #15's review of the medical records found no evidence documenting interventions related to Patient #1501's Medical Problem of Failure to Thrive or Poor Intake, prior to the 06/14/21 Initial Nutritional Assessment performed by the RD (19 days after the Patient's admission).

8. On 06/17/18 at approximately 4:00 AM, staff found Patient #1501 unresponsive. No pulse was detected. A Code Blue was initiated and 911 was called. Resuscitation efforts continued until 5:10 AM with the arrival of Emergency Medical Services (EMS) and included the use of an automated defibrillator (AED), which detected "no shockable rhythm." The deceased Patient was transported to Evergreen Monroe Emergency Department.

Patient #1505

9. On 07/20/21 at 11:30 AM, Investigator #15, and a Registered Nurse (RN) (Staff #1508), reviewed the medical record for Patient #1505, a 58-year-old male, who was admitted on 03/28/21 for Schizoaffective Disorder. The Patient had a reported medical history of Diabetes and labs obtained in the Emergency Department prior to admission indicated that his glucose was 559 mg percent. Upon admission, the Patient presented as disorganized, paranoid, tangential, with pressured speech. The Patient reported that he had not been taking any medications. The record review showed the following:

a. On the Initial Nursing Assessment, dated 03/28/21, nursing staff documented that Patient #1505's Body Mass Index (BMI) was 18.1. The Nutritional Screen noted that a BMI score less than 19 requires a Dietary Consult. However, the Nutritional Screening score for Patient #1505 was zero, not triggering the need for a Dietary Consult.

b. The History and Physical Assessment, dated 03/28/21, the Medical Provider checked the box marked "none" for review of problems with the Endocrine (Diabetes) system. The Master Treatment Problem List for Medical listed Diabetes as an active problem. The Medical Provider initiated a Treatment Plan for sliding scale insulin, noting "it is unclear whether he will accept most of these treatments."

c. On the Individual Treatment Plan for Diabetes, dated 03/31/21, nursing staff "crossed out" the intervention for a dietary consult for evaluation of present diet and educate the patient regarding dietary needs.

d. Investigator #15's review of the Weekly Treatment Plan Updates, dated between 04/07/21 to 07/19/21, found nursing staff documented that Patient #1505 was "non-compliant and refusing medications" for his Diabetes. Investigator #15 found no evidence of staff documenting additional interventions to support the Patient's recovery, including a Dietary/Nutritional Consult.

e. Investigator #15's review of the Medical Provider's Medical Consult Notes dated between 03/30/21 to 07/12/21, showed the following:

i. On 03/30/21, Patient #1505 stated that "insulin is not useful, the food he is eating here will just keep making his sugars go up." No Dietary Consult was ordered.

ii. On 04/02/21, staff reported Patient #1505 was "upset that he was given pork and that he doesn't eat pork." No Dietary Consult was ordered.

iii. On 04/06/21, after Patient was refusing supplements, staff documented that the patient was educated regarding the importance of drinking his Glucerna to prevent hypoglycemia (low blood sugar) in the morning and to increase body weight. No Dietary Consult was ordered.

iv. On 04/26/21, the Medical Provider documented the Patient's HBA1c (average level of blood sugar over the past 2 to 3 months) was 14.4 (. The Medical Provider educated the Patient to eat a "more restrained diet, or his daytime sugars will never be lower than they are now." Staff documented that interventions for the Patient's uncontrolled Diabetes is running up against the factor of the Patient's diet. No Dietary Consult was ordered.

v. On 05/17/21, the Medical Provider documented that the Patient's fasting blood glucose levels ranged from 185 to 449. The Medical Provider documented that they will "hold the Patient's snacks unless he is willing to take Novolog (insulin) at mealtime." No Dietary Consult ordered.

vi. On 05/24/21, the Medical Provider documented that he "stopped him (Patient #1505) from getting snacks, but he still has never agreed to take the insulin. I feel that we have restricted his carbohydrate intake as much as we can without affecting his nutritional status." No Dietary Consult ordered.

vii. On 07/12/21, the Medical Provider documented that he suggested to Patient #1505 that he might be eating something for lunch or his snack between lunch and dinner that could be causing problems (with his blood sugar readings). No Dietary Consult ordered.

f. Investigator #15's review of the Physician's Orders dated between 03/28/21 to 07/19/21, found no evidence of a Physician's Order for a Dietary Consult for Patient #1505.

g. On 07/20/21 at 12:57 PM, nursing staff documented on a Daily Nursing Progress Note Addendum that the RN called the Dietitian at Evergreen-Monroe to order a Dietary Consultation for Patient #1505 (116 days after the Patient's admission).

h. On the Daily Nursing Progress Note dated 07/21/21, staff documented that Patient #1505 discharged.

i. Investigator #15's review of Patient #1505's medical record found no evidence that staff performed the initial Dietary Consult which should have been triggered based on the Patient's BMI during admission on 03/28/21. Throughout the Patient's admission, from 03/28/21 to 07/21/21, Investigator #15 found no evidence that staff documented the re-evaluation of the Patient's progress towards the goals to stabilize the Medical Problem of Diabetes, or initiated modifications and/or appropriate interventions to the treatment plan.

10. On 07/20/21 at 11:45 AM, during an interview with Investigator #15, Staff #1508 verified that Patient #1505 did not receive a Dietary/Nutritional Consultation for the management of his uncontrolled Diabetes during his admission. Staff #1508 stated that "we can't go back now and fix that." The RN stated that the patient's progress towards their psychiatric and medical goals is discussed in Treatment Team. Any changes to the Patient's treatment plan would be updated at that time and communicated to the rest of the team. Staff #1508 verified that the medical record for Patient #1508 did not document any changes to the course of treatment for the Patient's uncontrolled Diabetes, other than the medication changes and titrations documented in the Psychiatric Providers Notes.

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Item #1 - NUTRITIONAL CONSULTS

Based on interview, document review, and medical record review, the hospital failed to ensure that patients assessed with nutritional deficiencies received a nutritional consultation assessment for 4 of 6 patients reviewed (Patient #1210, #1501, #1503 and #1505).

Failure to provide patients with necessary nutritional assessments places patients at risk for delay in receiving appropriate treatments and serious injury, including death.

Findings included:

1. Document review of the hospital's form titled, "Initial Nursing Assessment," revised 12/20, showed that a registered nurse (RN) will assess the patient's nutritional status within 8 hours of admission to the hospital. The document showed that nutritional screen scores greater or equal to 15, or a body mass index (BMI) less than 19, requires a dietary consult.

Document review of the hospital's policy and procedure titled, "Plan of Provision of Care-Scope of Services," policy number 1000.0, revised 06/21, showed that a nutritional assessment is completed by the Registered Dietician within 72 hours of a written order by the physician with the scope to include dietary needs, preferences, and habits.

Patient #1210

2. Document review of the medical record showed that Patient #1210 was admitted on 02/20/21 on an involuntary hold, for the treatment of schizoaffective disorder and altered thought processes. Pertinent medical history showed that the patient had chronic kidney disease stage III, insulin dependent diabetes, high blood pressure, chronic obstructive pulmonary disease, and sleep apnea.

a. The Initial Nursing Assessment, completed on 02/20/21 at 2:00 AM, showed that the patient scored a 15 on the nutritional screen score for kidney disease. The document showed that the nurse checked the "Yes" box indicating that a Nutritional Consult was ordered.

b. The Admission Orders, completed on 02/20/21 at 04:15 AM, and signed by the medical provider on 02/20/21 at 11:00 AM, showed that a diabetic diet was ordered, but the box for dietary consult was not checked.

c. The Physicians Orders dated 02/20/21 through 03/12/21 showed that there was no order for a Nutrition Consult entered during the time that Patient #1210 was admitted to the facility.

Patient #1501

3. On 07/12/21 at 10:30 AM, Investigator #15, and a Registered Nurse (RN) (Staff #1507), reviewed the medical record for Patient #1501, a 64-year-old male, who was admitted on 05/26/21 for Grave Disability. The Patient had a reported past psychiatric diagnosis of Schizoaffective Disorder, reported a weight loss of approximately 50 pounds in the previous 6 months, and presented as disorganized, malodorous, and cachectic (weakness and wasting of the body due to severe chronic illness). The Patient had been hospitalized in January of 2021 for Grave Disability and Failure to Thrive (FTT). The record review showed the following:

a. On the Initial Nursing Assessment-Nutritional Screening, dated 05/26/21, nursing staff documented that Patient #1501 scored a 20, based on an eating disorder and recent weight loss in past 90 days. The Nutritional Screening showed that staff checked the "YES" box indicating that a Dietary/Nutritional Consult was ordered.

b. Review of the Admission Order, dated 05/26/21, and signed by the Psychiatric Provider on 05/26/21 at 9:30 AM, showed that the box for Dietary Consult was not checked.


c. On the History and Physical Assessment, dated 05/26/21, the Medical Provider initiated a Master Problem List for medical problems for Patient #1501, adding the medical problem "Failure to Thrive," including interventions to obtain a Dietary Consult to "best support weight gain in patient and explore possible diet-related reasons for weight loss."

d. On 05/26/21 at 11:58 AM, the Medical Provider initiated a written Physicians Order for a Dietary Consult for "severe failure to thrive and weight loss." On 05/26/21 at 6:00 PM, staff documented that the order was "faxed" to the Dietary Service staff.

e. On 06/03/21 at 3:40 PM, the Medical Provider initiated a Physicians Order for a Dietary Consult for "low weight, Body Mass Index (BMI) 15." On 06/12/21 at 8:09 AM, (9 days after the order was initiated), staff documented that the order was "faxed" to the Dietary Service staff.

f. Investigator #15 found no evidence of a Dietary/Nutritional Consult for Patient #1501 between 05/26/21 and 06/13/21.

g. On 06/14/21 at 3:29 PM, a Registered Dietitian (RD), conducted an initial Nutrition Assessment for Patient #1501, 19 days after the Patient was admitted to the hospital.

4. On 07/12/21 at 2:10 PM, during an interview with Investigator #15, a Registered Nurse (RN) (Staff #1503) verified that the Nutritional Assessment dated 06/14/21 appeared to be the first Nutritional Assessment Patient #1501 received. Staff #1503 stated that the nurses tell the providers when a patient needs a Dietary/Nutritional Consult ordered. Staff #1503 was unsure of who was responsible to follow up after the order is initiated.

Investigator #15 found no evidence that Patient #1501 received a Nutritional Assessment before 06/14/21 (19 days after admission).

Patient #1503

5. On 07/13/21 at 11:30 AM, Investigator #15, and a Registered Nurse (RN) (Staff #1507), reviewed the medical record for Patient #1503, a 73-year-old female, who was admitted on 05/09/21 for Depression and Failure to Thrive (FTT). The Patient had a reported past psychiatric diagnosis of Bipolar Disorder and presented with racing thoughts and not eating or drinking. The Patient reported that she had not been taking any medications for at least 3 years. The record review showed the following:

a. On the Initial Nursing Assessment-Nutritional Screening, dated 05/09/21, nursing staff documented that Patient #1503 scored 15, based on poor appetite, recent diarrhea, and recent weight loss in past 90 days. The Nutritional Screening showed that staff checked the "YES" box indicating that a Dietary/Nutritional Consult was ordered.

b. Review of the Admission Order, dated 05/09/21, and signed by the Psychiatric Provider on 05/09/21 at 10:00 AM, showed that the box for Dietary Consult was not checked.

c. On 05/09/21, the diagnosis of Diabetes was added to the Master Treatment Plan Problem List and an Individual Treatment Plan for Diabetes was initiated. The treatment plan included an intervention dated 05/09/21, to obtain a Dietary Consult for the evaluation of the Patient's present diet and to educate the Patient regarding dietary needs.

d. Investigator #15's review of the Physician's Orders dated between 05/09/21 to 06/02/21, found no evidence of a Physician's Order for a Dietary Consult for Patient #1503.

6. On 07/13/21 at 11:34 AM, during an interview with Investigator #15, (Staff #1507) Staff #1507 verified that the medical record failed to show that a Dietary consult was ordered for Patient #1503 between 05/09/21 and 06/02/21, when the Patient was discharged to the hospital for medical intervention. Staff #1507 stated that the Patient's Nutritional Score on the Initial Nursing Assessment and the Individual Diabetes Treatment Plan intervention for a Dietary Consult, should have triggered an order for a Dietary Consult.

Patient #1505

7. On 07/20/21 at 11:30 AM, Investigator #15, and a Registered Nurse (RN) (Staff #1508), reviewed the medical record for Patient #1505, a 58-year-old male, who was admitted on 03/28/21 for Schizoaffective Disorder. The Patient had a reported medical history of Diabetes and labs obtained in the Emergency Department prior to admission indicated that his glucose was 559 mg percent. Upon admission, the Patient presented as disorganized, paranoid, tangential, with pressured speech. The Patient reported that he had not been taking any medications. The record review showed the following:

a. On the Initial Nursing Assessment, dated 03/28/21, nursing staff documented that Patient #1505's Body Mass Index (BMI) was 18.1. The Nutritional Screen noted that a BMI score less than 19 requires a Dietary Consult. However, the Nutritional Screening score for Patient #1505 was zero, not triggering the need for a Dietary Consult.

b. Investigator #15's review of the Physician's Orders dated between 03/28/21 to 06/02/21, found no evidence of a Physician's Order for a Dietary Consult for Patient #1505.

8. On 07/20/21 at 11:45 AM, during an interview with Investigator #15, Staff #1508 verified that the medical record failed to show that a Dietary consult was ordered for Patient #1505 between 03/28/21 and 07/20/21. Staff #1508 stated that the Patient's BMI Score on the Initial Nursing Assessment should have triggered an order for a Dietary Consult.

Item #2 - NUTRITIONAL INTAKE DOCUMENTATION

Based on interview, record review, and review of policies and procedures, the hospital failed to ensure that staff recorded the nutritional intake assessment following each meal for 13 of 20 patients reviewed (Patients #1201, #1202, #1203, #1204, #1205, #1206, #1207, #1208, #1209, #1501, #1502, #1503, and #1505).

Failure to accurately monitor and record patients' nutritional intake can result in the inappropriate, inconsistent, or delayed treatment of patients' needs and may lead to patient harm and lack of appropriate treatment for a medical condition.

Findings included:

1. Document review of the hospital's policy titled, "Charting Requirements," policy number 1000.87, reviewed 06/21, showed that the mental health technician (MHT) or licensed practical nurse (LPN) will complete a note that includes patient food intake. The document showed that in order to ensure accuracy, notes should be entered as quickly as possible following significant events.

2. On 07/20/21, Investigator #12, the Assistant Director of Nursing (Staff #1201), and the Director of Risk Management (Staff #1202) reviewed the medical record for 15 patients admitted to the adult inpatient psychiatric units between 07/15/21 and 07/19/21. The document review showed that staff failed to record the patient's nutrition intake following breakfast, lunch, or dinner, for 73 of 264 observations (Patients #1201, #1202, #1203, #1204, #1205, #1206, #1207, #1208 and #1209). Staff #1201 confirmed the information was missing and should have been documented in the medical record.

3. On 07/20/21, Investigator #15 and a Registered Nurse (Staff #1508), reviewed the medical records for 5 patients admitted between 05/01/21 and 07/19/21. The document review showed that staff failed to record the patient's nutrition intake following breakfast, lunch, and/or dinner for 129 of 149 days (Patient #1501, 1502, #1503, and #1505). Staff #1508 verified that the information was missing and the Mental Health Technician (MHT) or nursing staff should have documented the patient's intake in the medical record.

4. On 07/14/21 at 12:25 PM, Investigator #12 and Investigator #15 interviewed the Charge Nurse (Staff #1203) at the Everett adult inpatient psychiatric unit. The interview showed that when patients eat meals in their rooms, they are supposed to bring their trays back to the dining hall so that staff can see how much food they have eaten, "but that does not always happen." Staff #1203 stated that if a patient does not bring their tray back to the dining room, they may not know if a person ate their meal. If a person does not eat, they are supposed to offer the patient snacks. If the patient continues to refuse meals, they are supposed to let the provider know.

5. On 07/20/21 at 6:00 PM, Investigator #12 and Investigator #15 interviewed the Chief Executive Officer (Staff #1204). The interview showed that since the COVID-19 outbreak occurred in 2019, patients have been taking meals in their room rather than eating in the cafeteria, and staff have had difficulty tracking the dietary intake of patients since they have been eating in their rooms instead of the cafeteria.

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Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure that nursing staff followed its procedure for identification of any allergies prior to medication administration, as demonstrated by medical record review (Patient #1210).

Failure to assess patients for allergies prior to administering medications places patients at risk of injury or death.

Findings included:

1. Document review of the hospital policy titled, "Medication Administration," policy number 28, approved 02/21, showed that before administering a medication to a patient, the authorized staff member must verify that there is no contraindication with respect to allergy, sensitivity, or diagnosis.

Review of the hospital policy and procedure titled, "Charge Nurse/Staff Nurse Position Description," no review date, showed that staff registered nurses (RNs) and charge nurses, will ensure that medications are administered safely, according to professional standards, and as directed by hospital policy and procedure.

2. Document review of the medical record showed that:

a. Patient #1210 was admitted on 02/20/21 for the treatment of schizoaffective disorder and altered thought processes. Pertinent medical history for Patient #1210 included stage III chronic kidney disease, insulin dependent diabetes, high blood pressure, chronic obstructive pulmonary disease, and sleep apnea.

b. The Call-to-Decision form dated 02/19/21, and the forms titled Initial Nursing Assessment and Admission Orders dated 02/20/21, showed that Patient #1210 was allergic to haloperidol, penicillin, pseudoephedrine, and Spiriva.

c. Review of the Inpatient Services Psychiatric Progress Note - 2nd Opinion Consultation form dated 02/23/21 at 10:30 AM, showed that Patient #1210 was evaluated by a psychiatrist, and the psychiatrist was in agreement with the medical provider's recommendation to use involuntary medications for the patient. The document did not contain information regarding Patient #1210's allergy to haloperidol.

d. On 02/23/21 at 11:12 AM, a telephone order was entered for assault and elopement precautions related to Patient #1210 demanding to leave, kicking and hitting exit doors, verbally threatening staff, and throwing water and tissue boxes at staff.

e. Review of the Physician Medication Orders showed that on 02/23/21 at 11:10 AM, an order for haloperidol 10mg intramuscularly, to be given once for agitation, was prescribed by a provider. On 02/23/21 at 12:00 PM, a second order for haloperidol 10mg by mouth once at 12:00 PM for psychosis was entered as a telephone order by nursing staff.

f. Document review of the Medication Administration Record showed that on 02/23/21 at 12:28 PM, a nurse (Staff #1203) administered haloperidol 10mg by mouth to the patient despite a documented allergy to the medication.
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