HospitalInspections.org

Based on policy review, medical record review and interview, the facility failed to promote all Patient Rights and ensure the patient's Conservator was informed of the patient's health status for 1 of 7 (Patient #2) sampled patients; and failed to ensure
all patients received care in a safe setting for 1 of 7 (Patient #2) sampled patients who displayed inappropriate sexual behaviors and attempted to inflict self-harm.

The findings include:

1. Review of the facility's "Abuse and Neglect, Patient" policy with a date of approval "12/2020" revealed, "...[Named Company] is committed to the safety and well-being of every patient...The family should be kept informed of what is happening to the patient at all times..."

Review of the facility's "Incident Reporting - Risk Management Program" policy last reviewed/revised "12/20" revealed, "...It enables the facility to manage risk, increase safety, and improve the quality of health care provided in the facility...If the incident involves a patient, staff must chart relevant information in the patient's medical record. When documenting incidents in the medical records, staff will chart precisely what happened without making reference..."

Review of the facility's "Observation, Patient" policy with a date of approval "12/2020" revealed, "...Staff documents all levels of observations on each patient's observation form which becomes a part of the patient record...It is not permissible to complete in advance or to back fill time frames that were not completed in a timely manner.

2. Patient #2 was admitted to the facility on 12/1/2021 and was experiencing angry outbursts.

The psychiatry progress note on 12/3/2021 revealed Patient #2 engaging in self harm behaviors.

Review of the nursing assessment dated 1/6/2022 at 7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM revealed Patient #2 was sexually inappropriate on both shifts.

Review of the nursing assessment dated 1/12/2022 at 7:00 PM -7:00 AM revealed Patient #2 was sexually inappropriate.

Review of the nursing assessment dated 1/18/2022 at 7:00 PM - 7:00 AM revealed Patient #2 was sexually inappropriate.

Review of the psychiatry progress notes dated 1/21/2022 Patient #2 engaged in oral sex.

The psychiatry progress note on 1/24/2021 revealed Patient #2 required several as needed (PRN) medication for self harm over the weekend.

Review of the nursing assessment dated 2/3/2022 at 7:00 AM -7:00 PM revealed Patient #2 was sexually inappropriate.

Review of the 24 hour pharmacy review revealed Patient #2 was being treated with Zpovirax for Herpes.

Review of the nursing assessment dated 2/20/2022 at 7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM revealed Patient #2 was sexually inappropriate on both shifts.

Review of the nursing assessment dated 2/24/2022 at 7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM revealed Patient #2 was sexually inappropriate on both shifts.

Review of the nursing assessment dated 3/3/2022 at 7:00 AM -7:00 PM revealed Patient #2 was sexually inappropriate.

Review of the nursing assessment dated 3/6/2022 at 7:00 AM -7:00 PM revealed Patient #2 was sexually inappropriate.

Review of the nursing assessment dated 3/7/2022 at 7:00 AM -7:00 PM revealed Patient #2 was sexually inappropriate.

Review of the Seclusion/Restraint packet on 3/8/2022 revealed Patient #2 and roommate being sexually inappropriate with each other.

Review of the nursing assessment dated 3/12/2022 at 7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM revealed Patient #2 was sexually inappropriate on both shifts.

Review of the nursing assessment dated 3/13/2022 at 7:00 AM -7:00 PM revealed Patient #2 was sexually inappropriate.

Review of the medical progress notes on 3/26/2022 revealed Patient #2 complained of vaginal discharge and ulcerations in genitals. The physician documented the patient had contracted Herpes #1 and #2 (sexually transmitted diseases) while in this facility.

The practitioner order sheet dated 3/26/2022 revealed orders for Valacyclovir, and a Urine for Gonorrhea/Chlamydia (sexually transmitted disease - there was no documentation this was done by the facility).

There was no documentation the facility developed and implemented safety precautions for the other patients at the facility to prevent the patients from sexual transmitted diseases from Patient #2.

Review of a facility's incident report dated 3/31/2022 revealed Patient #2 was involved in a patient to patient altercation where Patient #2 got punched in the Left jaw. There was no documentation the patient's physician was notified to the patient was assessed for an injury. There was no documentation interventions were developed and implemented to prevent further patient to patient altercations.

The facilty was unable to provide any documentation that the conservator was notified of the incident on 3/31/2022.

A telephone interview on 4/7/2022 at 11:27 AM Patient #2's mother stated she was not notified of her daughter getting punched in the jaw.

In an interview on 4/7/2022 at 1:10 PM the Registered Nurse (RN) #1 stated she did not notify Patient #2's conservator of the incident.

In an e-mail correspondence on 4/7/2022 with the Director of Risk Management, the Director was asked if anything had been done to address Patient #2's inappropriate sexual behavior. The Director did not respond to this question.

Refer to 131 and 144.

Based on record review, document review, and interview, the facility failed to ensure the family/Conservator was notified of a change in the condition of the patient for 1 of 1 (Patient #2) sampled patients who had a change in condition in which the family/Conservator was not notified.

The findings included:

1. Review of the facility's "Abuse and Neglect, Patient" policy with a date of approval "12/2020" revealed, "...[Named Company] is committed to the safety and well-being of every patient...Patients have the right to be free from mental, physically, sexual and verbal abuse...[Named Behavioral Hospital] shall protect patients from real or perceived abuse, neglect or exploitation from anyone...other patients...All cases of suspected abuse/neglect/exploitation as defined in this policy, whether or not an actual injury has occurred, will be reported and investigated promptly in compliance with state law and regulation...The family should be kept informed of what is happening to the patient at all times..."

Review of the facility's "Incident Reporting - Risk Management Program" policy last reviewed/revised "12/20" revealed, "...It enables the facility to manage risk, increase safety, and improve the quality of health care provided in the facility...If the incident involves a patient, staff must chart relevant information in the patient's medical record. When documenting incidents in the medical records, staff will chart precisely what happened without making reference to an "error"...Risk Manager must review and sign all Incident Reports. Recommendations and/or outcomes should be noted on the Incident Report...Any allegation of action, behavior, or relationship between Pt [patient/Pt [patient] that could interfere with a safe, therapeutic environment and care at the facility..."

2. Medical record review revealed Patient #2 was admitted to the facility on 12/1/2021 with an admitting diagnoses which included Schizoaffective Disorder- Bipolar Type.

Review of the facility's incident report dated 3/31/2022 with the time documented as, " the time of the incident was during dinner time", revealed, "...[Patient #2] was at nursing station talking to nurse, upset because music therapist didn't come to the unit, pulled off her shirt. [Patient #3] told her to put her shirt on, they began cursing each other, and [Patient #3] hit her in the jaw....Was family or others notified...yes...[Patient #2's] mother/conservator...were police notified...yes...Client care incident...injury...urgent care...no..."

The facility was unable to provide documentation Patient #2's family/Conservator was notified of Patient #2 being hit by Patient #3.

In an telephone interview on 4/7/2022 at 11:17 AM Patient #2's mother stated, "...I did not receive a call from the [Named Hospital #1] about [Patient #2] getting punched in the jaw. [Patient #2] told me about her jaw on the phone..."

In an interview on 4/7/2022 at 1:10 PM the Registered Nurse (RN) #1 was asked if the patient's mother/conservator was notified of Patient #2's jaw injury. RN #1 stated, "...No, I did not call anybody..."

Based on policy review, document review, medical record review and interview, the hospital failed to ensure patients received care in a safe setting to prevent 1 of 7 (Patient #2) sampled patients from sexually inappropriate behaviors with other patients and to prevent Patient #2 from intentional self-harm behaviors

The findings include:

1. Medical record review revealed Patient #2 was admitted to the facility on 12/1/2021 with admitting diagnoses which included Schizoaffective Disorder -Bipolar Type.

Review of psychiatry progress notes on 12/3/2021 revealed, "...Engaging in self harm behaviors very attention seeking..."

Review of the nursing assessment on 1/6/2022 - 7:00 AM - 7:00 PM revealed in the narrative notes, "...Pt [Patient]...sexually inappropriate..."

Review of the nursing assessment on 1/6/2022 at 9:30 PM revealed in the narrative notes, "...Pt [Patient]...sexually inappropriate [symbol for with] female peers..."

Review of the nursing assessment on 1/12/2022 - 7:00 PM - 7:00 AM revealed in the narrative notes, "...Pt [Patient] AA0 [oriented to person, place and time]...Impulsive, Hyperactive. Sexually inappropriate [symbol for with] pts [patients] and inanimate objects..."

Review of the nursing assessment on 1/18/2022 - 7:00 AM - 7:00 PM revealed in the narrative notes, "...Pt [Patient]...sexually inappropriate..."

Review of the psychiatry progress notes on 1/21/2022 revealed, "...Engaged in oral sex with a peer last night..."

Review of the psychiatry progress notes on 1/24/2022 revealed, "...Several PRN [ as needed medication] over the weekend for ongoing self harm behaviors..."

Review of the nursing assessment on 1/29/2022 - 7:00 AM - 7:00 PM revealed in the narrative notes, "...Pt [Patient]...sexually inappropriate...Pt [Patient] had to be redirected multiple times for touching male peer..."

Review of the nursing assessment on 2/3/2022 -7:00 AM - 7:00 PM revealed in the narrative notes, "...Pt [Patient]...sexually inappropriate..."

Review on nursing assessment on 2/9/2022 - 7:00 AM - 7:00 PM in the narrative notes revealed, "...Pt [patient] is c/o [complain of] mouth/vaginal sores. R/t [related to] sexual intercourse. Pt. [patient] prescribed Acyclovir [used to teat herpes] from medical doctor. Attention seeking sexually inappropriate..."

Review of the practitioner order set on 2/9/2022 at 7:36 AM revealed and order for Acyclovir 400 milligrams (mg) 1 tablet by mouth three times a day for 7 days (medicine used to treat genital herpes and herpes infections of the mouth).

Review of an 24 hour pharmacy review on 2/9/2022 at 1:03 PM revealed, "...Current Treatment Zpovirax 400 mg three times a day for 7 days for diagnosis of herpes infection.

Review of the 48 hour practitioner review on 2/13/20222 at 8:36 AM revealed, "...There are signs of infection. continue treatment as written.

Review of the nursing assessment on 2/20/2022 -7:00 AM - 7:00 PM revealed in the narrative notes, "...Pt [Patient]...sexually inappropriate..."

Review of the nursing assessment on 2/20/2022 at 11:00 PM revealed in the narrative notes, "...Pt [Patient was sexually inappropriate -Dancing in an inappropriate manner - twerking] Required prn [as needed] Haldol, Benadryl and Ativan to calm her..."

Review of the nursing assessment on 2/24/2022 7:00 AM - 7:00 PM revealed in the narrative notes, "...Pt [Patient] is at her baseline - Attention seeking, sexually inappropriate..."

Review of the nursing assessment on 2/24/2022 at 9:03 PM revealed in the narrative notes, "...Pt [Patient] remains sexually inappropriate..."

Review of the nursing assessment on 3/3/2022 - 7:00AM - 7:00 PM revealed in the narrative notes, "...Pt [Patient] is at her baseline - Attention seeking sexually inappropriate, manic, obsessive..."

Review of the nursing assessment on 3/6/2022 - 7:00AM - 7:00 PM revealed in the narrative notes, "...Pt [Patient] is at her baseline - obsessive, attention seeking, sexually inappropriate..."

Review of the nursing assessment on 3/7/2022 - 7:00AM - 7:00 PM revealed in the narrative notes, "...Pt [Patient] is attention seeking, manic, obsessive and sexually inappropriate..."

Review of the Seclusion/Restraint Packet on 3/8/22 revealed, "...Pt [patient] and roommate cutting themselves and licking each others blood, also putting crayons in their vagina..."

Review of the nursing assessment on 3/12/2022 - 7:00AM - 7:00 PM revealed in the narrative notes, "...Pt [Patient] is manic, impulsive, attention seeking and sexually inappropriate..."

Review of the nursing assessment on 3/12/2022 at 9:30 revealed in the narrative notes, "...sexually inappropriate..."

Review of the nursing assessment on 3/13/2022 - 7:00 AM - 7:00 PM narrative notes revealed, "...Pt [patient] is manic, labile, delusional;, attention seeking, sexually inappropriate.

Review of medical progress note on 3/26/22 at 9:42 AM revealed, "...Chief Complaint (In the patient's own words): vaginal discharge, ulcerations in genitals...History of Present Illness: hx [history] of HSV [Herpes Simplex Virus] 1 & [and] 2 that was contracted while in [Named Facility]. Admits to sexual intercourse with two people since being here. Reports brownish vaginal discharge and itching...did not examine genitalia...HSV [Herpes Simplex Virus] outbreak, potential exposure to STD's [Sexual Transmitted Disease's]...high risk sexual behavior...Plan urine for GC [Gonorrhea/Chlamydia] then treat..."

Review of the practitioner order sheet on 3/26/2022 at 9:47 AM revealed orders for Valacyclovir one by mouth every day for Herpes Simples Virus, obtain a
Urine sample for Gonorrhea]/Chlamydia and once obtained administer Rocephin 500 mg Intramuscular 1 time and Azithromycin 2 grams orally as a single dose. There was no documentation the urine sample was obtained.

There was no documentation the facility developed and implemented safety measures to prevent Patient #2 from exhibiting and performing sexually inappropriate behaviors with the other patients.

In an e-mail correspondence on 4/7/2022 the Director of Risk Management was asked what safety interventions had been implemented to protect the other patients from sexually transmitted diseases and the Director of Risk Management did not respond to the question.

In an interview on 4/7/2022 beginning at 1:16 PM Director of Risk Management was asked if self harm should have been listed as a problem on the Initial Treatment Plan and the DRM stated, "...Yes..."

Based on policy review, medical record review and interview, the hospital failed to have an organized nursing service which provided ongoing assessments of patients needs, assessed patients' pain and the effectiveness pain medications, notified the physician of incomplete lab tests, documented patient incidents in the patient's medical record and failed to ensure there was a physican order prior to administering anti-psychotic medications for 4 of 6 (Patient #2, #3, #4 and #5) sampled patients.

The findings include:

1. Review of the facility's policy "ASSESSMENT/REASSESSMENT" dated 12/2020 revealed, "...Pain assessments are also conducted following administration of pain medications..."

Review of the facility's policy "MEDICATION ADMINISTRATION AND DOCUMENTATION" dated 2/2022 revealed, "...P.R.N. [as needed] medications must be specific...Effect of the P.R.N. medication must be documented after 1 hour of giving medication....Pain Medication... the nurse shall assess the patient's level of pain (0-10) and document on the Medication form and progress note...Document the effectiveness of the medication including the level of pain after a reasonable length of time based on route of administration of the medication..."

Review of the facility's "LABORATORY SERVICES" policy reviewed on "12/2020" revealed, " ...Lab test will be attempted for three days with the physician being notified of inability to obtain the specimen...will be complete within 24 hours..by nurse or called by lab to MD..."

2. Patient #2 was admitted on 12/1/2021 with angry outburst and mania/aggression with admitting diagnoses which included Schizoaffective Disorder -Bipolar Type.

(a) Review of the patient's medications revealed the following:

The Medication Administration Record (MAR) dated 3/26/2022 - 4/5/2022 revealed three as needed (PRN) medications were administered; Ativan Injection 2 milligrams (mg), Benadryl Injection 50 mg and Haldol Injection 5 MG mg. The nurse documented these medications were administered for agitation. There was no reassessment following the administration to determine the effectiveness of the medications.

Review of the MAR dated 3/27/2022 revealed Motrin was administered for pain. There was no assessment or reassessment documented for this pain medication.

The nursing assessment dated 4/2/2022 documented the patient had a swollen left jaw and a pain scale of 5. The MAR dated 4/2/2022 at 6:57 PM documented Tylenol was administered for the patient's complaints of pain. There was no documented pain assessment of reassessment of the Tylenol that was administered.

The psychiatry progress notes on 4/5/2022 revealed Patient #2's jaw was still hurting.

Interview on 4/7/2022 at 1:10 PM RN #1 stated that pain is assessed every 30 minutes and it is documented in the progress notes.

(b) Review of the patient's Laboratory Test revealed:

A Medical progress notes dated 3/26/2022 documented the patient's chief complaint was a vaginal discharge and ulcerations in the genitals. The patient admitted to having sexual intercourse with two (2) patients while at this facility. A Urine test was ordered to test the patient for Gonorrhea/Chlamydia (sexually transmitted disease) and after the test is performed the patient was to receive to an intramuscular injection of Rocephin and a Azithromycin oral a one time dose. There was no documentation the Urine test was performed.

Interview on 4/7/2022 the Director of Risk Management stated the physician should have been notified of the inability of the staff to obtain a Urine test on Patient #2.

In a telephone Interview on 4/7/2022 Nurse Practitioner (NP) #2 stated that she was not notified Patient #2 had refused the Urine test.

3. Medical record review for Patient #3 revealed the patient was admitted to the facility on 3/27/2022 with medications non-compliance and with diagnoses which included Schizoaffective Disorder, Bipolar Type.

An incident report dated 3/31/2022 revealed Patient #3 had punched Patient #2 in the Left Jaw

There was no documentation in the nursing assessment dated 3/31/2022 of the incident of Patient #3 punching Patient #2 in the jaw.

In an interview on 4/7/2022 the Director of Risk Management verified the incident should have been documented in the patient's medical record.

4. Medical record review revealed Patient #4 was admitted to the facility on 3/14/2022 with impulsive and inappropriate behaviors and with diagnoses which included Bipolar Disorder, Current Episode Depressed, Severe, without Psychotic Features.

A incident report dated 4/2/2022 documented Patient #4 had kicked Patient #5 in the face and was immediately given an intramuscular injection of three (3) medications which consisted of Zyprexa, Benadryl and Ativan. There was no documentation of a physician's order to administer the Zyprexa with the Benadryl and Ativan.

The nursing assessment dated 4/2/2022 stated the doctor was notified and orders for PRN medications was ordered however the nurse had already administered the medications before they notified the doctor.

5. Medical record review for Patient #5 revealed the patient was admitted on 3/26/2022 with thoughts of attempting to harm self and staff at the previous facility and with diagnoses which included Schizoaffective Disorder - Bipolar Type.

Review of the nursing assessment dated 4/2/2022 revealed Patient #5 was kicked in the nose by another patient while outside during a smoke break. The nurse documented in the progress note that she administered 2 Tylenol to the patient for pain. There was no documentation on the patient's MAR the patient had received the Tylenol or a reassessment of the patient following the Tylenol medication.

Refer to A395.

Based on policy review, medical record review and interview, the hospital failed to have an organized nursing service which provided ongoing assessments of patients needs, assessed patients' pain and the effectiveness pain medications, notified the physician of incomplete lab tests, documented patient incidents in the patient's medical record and failed to ensure there was a physician order prior to administering anti-psychotic medications for 4 of 6 (Patient #2, #3, #4 and #5) sampled patients.

The findings include:

1. Review of the facility's policy "ASSESSMENT/REASSESSMENT" dated 12/2020 revealed, "...Reassessments are completed by the registered nurse on day and evening shifts and documented on the nursing reassessment form...In addition each patient is reassessed as necessary...including change in the patients level of pain...minimum two times per day...Pain assessments are also conducted following administration of pain medications..."

Review of the facility's policy "MEDICATION ADMINISTRATION AND DOCUMENTATION" dated 2/2022 revealed, "...PRN [as needed] Medications...The dosage, route, time interval and reason for PRN medications must be specific...Effect of the PRN medication must be documented after 1 hour of giving medication....Pain Medication...Prior to administration of a medication designated for Pain Management, either a routine or PRN medication, the nurse shall assess the patient's level of pain (0-10) and document on the Medication form and progress note...Document the effectiveness of the medication including the level of pain after a reasonable length of time based on route of administration of the medication..."

Review of the facility's "LABORATORY SERVICES" policy reviewed on "12/2020" revealed, " ...Lab test will be attempted for three days with the physician being notified of inability to obtain the specimen ..."

2. Medical record review revealed Patient #2 was admitted to the facility on 12/1/2021 with admitting diagnoses which included Schizoaffective Disorder, Bipolar Type.

(a) Review of the patient's Medication administration revealed the following:

The patient's Medication Administration Record (MAR) dated 3/26/2022 at 8:30 PM three (3) as needed (PRN) medications were administered to the patient for agitation; Ativan Injection 2 milligrams (mg), Benadryl Injection 50 mg and Haldol Injection 5 MG mg. There was no reassessment for effectiveness of this medication.

Review of the MAR dated 3/27/2022 at 3:28 PM Motrin 200 mg tablet was administered for pain. There was no assessment and reassessment of the patient's pain or an assessment for the effectiveness of the pain medication.

Review of the MAR dated 3/27/2022 at 5:35 PM revealed three (3) PRN medications were administered to the patient for agitation; Ativan Injection 2 milligrams (mg), Benadryl Injection 50 mg and Haldol Injection 5 MG mg. There was no reassessment for effectiveness of this medication.

Review of the MAR dated 3/28/2022 at 9:30 AM three (3) PRN medications were administered to the patient for agitation; Ativan Injection 2 milligrams (mg), Benadryl Injection 50 mg and Haldol Injection 5 MG mg. There was no reassessment for effectiveness of this medication.
.
Review of the MAR dated 3/28/2022 at 7:53 PM revealed three (3) PRN medications were administered to the patient for agitation; Ativan Injection 2 milligrams (mg), Benadryl Injection 50 mg and Haldol Injection 5 MG mg. There was no reassessment for effectiveness of this medication.

Review of the MAR dated 3/29/2022 at 7:50 PM revealed three (3) PRN medications were administered to the patient for agitation; Ativan Injection 2 milligrams (mg), Benadryl Injection 50 mg and Haldol Injection 5 MG mg. There was no reassessment for effectiveness of this medication.

Review of nursing assessment dated 3/31/2022 at 9:00 PM revealed the patient complained of no pain according to the pain scale. In the nursing narrative notes it was documented that Patient #2 complained of Left jaw pain following a patient to patient altercation earlier. There was no documentation pain medication was administered until 9:55 PM when the patient was administered Motrin 200 mg. There was no documentation of a reassessment of the patient's pain.

Review of nursing assessment dated 4/2/2022 at 10:40 AM revealed under the section titled Medical/Physical Update the nurse documented the patient complained
of jaw pain and had a new medical problem of a swollen left jaw. Under the pain assessment section the nurse documented the patient complained of pain at a 5 on a scale of 1 -10 with 10 being the most painful. The nurse documented the location of the pain was the left jaw, the type of pain was acute, and the character of the pain was throbbing and aching. There was no documentation of any pain medication being giving until 9:55 PM.

Review of the MAR dated 4/2/2022 at 6:57 PM Tylenol 325 milligram (mg) was administered for pain. There was no assessment of the patient's pain and no documentation of a reassessment for the effectiveness of this pain medication.

Review of the MAR dated 4/2/2022 at 9:10 PM revealed three (3) PRN medications were administered to the patient for agitation; Ativan Injection 2 milligrams (mg), Benadryl Injection 50 mg and Haldol Injection 5 MG mg. There was no reassessment for effectiveness of this medication.

Review of the MAR dated 4/4/2022 at 9:05 PM revealed three (3) PRN medications were administered to the patient for agitation; Ativan Injection 2 milligrams (mg), Benadryl Injection 50 mg and Haldol Injection 5 MG mg. There was no reassessment for effectiveness of this medication.

Review of the nursing assessment dated 4/4/2022 at 7:00 PM - 7:00 AM revealed, " ...Given PRN [Ativan Injection 2 mg, Benadryl Injection 50 mg and Haldol Injection 5 MG mg] per request will continue to monitor..." The physician's order was to administer for agitation. There was no documentation the patient was agitated at the time the patient requested the medication.

Review of the MAR dated 4/5/2022 at 9:00 PM revealed three (3) PRN medications were administered to the patient for agitation; Ativan Injection 2 milligrams (mg), Benadryl Injection 50 mg and Haldol Injection 5 MG mg. There was no reassessment for effectiveness of this medication.

In an interview on 4/7/2022 beginning at 1:10 PM the Registered Nurse (RN) #1 was asked how often were reassessment performed following administration of pain medication and RN #1 stated, "...30 minutes..."
RN #1 was asked where was the effectiveness of the pain medication documented and RN #1 stated, "...I guess we would write it in a progress note..."
RN #1 was asked how often should pain be reassessed and RN #1 stated, "...When I am giving them [the patients] their other medication I ask them about pain at that time and it they are having pain I will give it [pain medications] to them then.

(b) Review of the patient's Laboratory Test revealed the following:

A Medical progress note dated 3/26/22 at 9:42 AM revealed, "...Chief Complaint (In the patient's own words): vaginal discharge, ulcerations in genitals...History of Present Illness: hx [history] of HSV 1 [Herpes Simplex Virus - one] & [and] 2 [two]that was contracted while in [Named Facility]. Admits to sexual intercourse with two people [patients]since being here. Reports brownish vaginal discharge and itching...did not examine genitalia...HSV [Herpes Simplex Virus] outbreak, potential exposure to STD's [Sexual Transmitted Disease's]...high risk sexual behavior...Plan urine for GCS [Gonorrhea/Chlamydia] then treat..."

Review of the practitioner order sheet on 3/26/2022 at 9:47 AM revealed the following orders:
Valacyclovir administer by mouth every day for Herpes Simples Virus and to obtain a Urine sample for Gonorrhea/Chlamydia. Once the urine sample is obtained administer Rocephin 500 milligrams (mg) Intramuscular once and Zithromycin 2 grams orally as a single dose. There was no documentation the Urine sample was obtained and the physician notified they were unable to obtain the Urine sample.

In an interview on 4/7/2022 beginning at 1:10 PM the Director of Risk Management was asked why was the patient's Urine sample was not obtained the Director stated, s "...Patient #2 refused it three times in a row".
The Director was asked if the physician should have notified and the Director stated, "...Yes".

In a telephone interview on 4/7/2022 beginning at 2:01 PM Nurse Practitioner (NP) #2 verified, " ...I was not notified that Patient #2 refused her lab ...ugh nobody notified me that she did not have that lab test and I had her an antibiotic ordered ..."

3. Medical record review revealed Patient #3 was admitted to the facility on 3/27/2022 with a diagnoses that included Schizoaffective Disorder, Bipolar Type.

Review of an incident report dated 3/31/2022 revealed Patient #3 was involved in a patient to patient altercation, "...[Patient #2] was at nursing station talking to nurse, upset because music therapist didn't come to the unit, pulled off her shirt. [Patient
#3] told her to put her shirt on, they began cursing each other, and [Patient #3] hit her [Patient #2] in the jaw....Was family or others notified...yes...[Patient #2's] mother/conservator...were police notified...yes...Client care incident...injury...urgent care...no..." There was no documentation the family/Conservator was notified.

Review of the nursing assessment dated 3/31/2022 and progress notes for the 7:00 AM - 7:00 PM shift revealed no documentation of the patient to patient altercation.

In an interview with the Director of Risk Management on 4/7/2022 beginning at 1:16 PM the Director was asked if the patient to patient altercation incident should have been charted in the nursing assessment or nursing progress notes and the Director stated, "Yes..."

4. Medical record review revealed Patient #4 was admitted to the facility on 3/14/2022 with a diagnoses which included Bipolar Disorder, Current Episode Depressed, Severe, without Psychotic Features.

Review of an incident report dated 4/2/2022 at 7:20 PM revealed Patient #5 was kicked in the face by Patient #4. The Patient was administered Zyprexa 10 mg, Benadryl 50mg and Ativan 2 mg for aggression to Patient #4 who kicked Patient #5.
The order was for the Patient to receive Benadryl, Ativan and Haldol. There was no documentation of an order for the Zyprexa.

5. Medical record review revealed Patient #5 was admitted to the facility on 3/26/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type.

Review of the nursing assessment on 4/2/2022 - 7:00 PM - 7:00 AM revealed, "...Patient was kicked in nose outside during smoke break. Bright red blood noted. Small superficial cut noted on top of nose. Pt [patient] given Tylenol x [times]2 tablets. Cold compress and applied gauze and Bandaid. Notified Doctor...D/DC'd [discharged] AMA [Against Medical Advice] @ [at]10:05 PM..." There was no documentation on the patient's MAR the Tylenol was administered and no documentation of a pain assessment or an assessment of the effectiveness of the pain medication.

Based on medical record review, the facility failed to maintain complete and accurate medical records in regards to patient identifiers for 3 of 6 patients (Patient #2, #4 and #5) sampled patients reviewed.

The findings include:

1. Review of the facilty's "Chart Order" policy with a reviewed date of "02/2020" revealed, "...To establish a standard order for filing and locating reports in the patient record...All documents shall be filed in the appropriate patient's medical record...Verification of the patient label is required to ensure documents are filed in the correct medical record".

Review of the facility's "MEDICATION ADMINISTRATION AND DOCUMENTATION" policy with a date of approval "02/2022" revealed, "...Verbal Orders/Telephone Orders...for medication shall be recorded promptly in the patient medical record...The prescriber shall countersign the medication order within (48) hours..."

Review of the facility's "SECLUSION" policy with a reviewed date of "09/2021" revealed, "...Seclusion may only be ordered by a psychiatrist...A trained registered nurse may initiate seclusion in the absence of a practitioner...The order shall indicate the reason and maximum duration of the seclusion..."

Review of the facility's "Observation, Patient" policy with a reviewed date of "12/2020" revealed, " ...Staff documents all levels of observations on each patient's observations form which becomes a part of the patient record..."

2. Medical record review revealed Patient #2 was admitted to the facility on 12/1/2021 with admitting diagnoses which included Schizoaffective Disorder, Bipolar Type.

(a) Review of the telephone/verbal orders revealed the following:
A telephone/verbal order dated 12/30/2021 at 1:00 PM revealed an order for seclusion which did not include the maximum duration for the seclusion and was unsigned by the physician.

A telephone/verbal order dated 12/31/2021 at 8:00 AM revealed an order for seclusion which did not include the maximum duration for the seclusion and was unsigned by the physician.

A telephone/verbal order dated 1/26/2022 at 3:00 PM revealed an order for urinalysis which was unsigned by the physician.

A telephone/verbal order dated 2/11/2022 at 10:45 AM revealed an order for Acyclovir 800 mg, Abreva 5mg, and Toradol 30 mg that was unsigned by the physician.

A telephone/verbal order dated 2/28/2022 at 5:20 PM revealed an order for seclusion which did not include the maximum duration for the seclusion and was unsigned by the physician.

A telephone/verbal order dated 3/31/2022 at 2:00 PM revealed an order for seclusion and was unsigned by the physician.

A telephone/verbal order dated 3/31/2022 at 6:00 PM revealed an order for Geodon 20 mg for agitation/aggression and was unsigned by the physician.

A telephone/verbal order dated 3/31/2022 at 6:00 PM revealed an order for Geodon 20 mg for agitation/aggression and was unsigned by the physician.

A telephone/verbal order dated 4/3/2022 at 8:40 PM revealed an telephone/verbal for Patient #2 to be transferred to the Emergency Room and was unsigned by the physician.

(b) Review of the Psychiatry progress notes revealed the following:
The Psychiatry progress notes dated 12/3/2021, 12/30/2021, 1/9/2022, 1/21/2022 and 1/24/2022 in Patient #2's medical record revealed no patient identifying information.

The Psychiatry progress notes dated 12/31/2021 revealed the only patient identifier was Patient #2's first name hand written in cursive at the right hand top of the form. Patient #2's first name was misspelled.

The Psychiatry progress notes dated 1/14/2022 and 1/9/2021 revealed illegible hand written name at the right hand top of the form.

A Practitioner order sheet dated 3/22/2022 at 3:21 PM in Patient #2's medical record revealed no documentation of patient identification on the order sheet.

(c) Review of the Observation forms revealed the following:
On 4/3/2022 the patient observation form documented Patient #2 was in the facility from 8:51 PM to 11:45 PM.

A Emergency Medical Service (EMS) report dated 4/3/2022 documented EMS departed from the facilty at 8:51 PM with Patient #2 going to an acute care Emergency Room and did not return to the facility until 4/3/2022 at 11:45 PM.

3. Medical record review revealed Patient #4 was admitted to the facility on 3/14/2022 with a diagnoses which included Bipolar Disorder, Current Episode Depressed, Severe, without Psychotic Features.

There was no documentation of an initial treatment plan in the medical record for Patient #4. In an interview on 3/9/2022 beginning at 2:03 PM Director of Risk Management was asked is there was an Initial Treatment Plan for Patient#4 and the Director stated, "...I looked and I did not find one..."

Review of a medication consent for psychotropics dated 3/14/2022 in Patient #4's medical record revealed no documentation of patient identification on the form.

A telephone/verbal order sheet dated 3/30/2022 at 1:25 PM revealed an order for Benadryl 50 mg, Ativan 2mg, and Haldol mg. There was no documentaion the physician had signed/verified this order.

A Interdisciplinary Treatment Plan Update - Treatment Team/Conference Date page one dated 3/29/2022 in Patient #4's medical record revealed no documentation of patient identification on the form.

A Interdisciplinary Treatment Plan Update - Nursing page 3 dated 4/4/2022 at 12:00 PM in Patient #4's medical record revealed no documentation of patient identification on the form.

4. Medical record review revealed Patient #5 was admitted to the facility on 3/26/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type.

A Interdisciplinary Treatment Plan Master Sheet dated 3/26/2022 revealed no documentation of signatures for nursing or the physician.

Refer to 450.

Based on medical record review and interview, the facility failed to ensure telephone and verbal orders were countersigned within the required time frame and the patients' medical forms had patient verification labels for 2 of 6 (Patient #2 and #4) sampled patients.

The findings include:

1. Review of the facilty's "Chart Order" policy with a reviewed date of "02/2020" revealed, "...To establish a standard order for filing and locating reports in the patient record...All documents shall be filed in the appropriate patient's medical record...Verification of the patient label is required to ensure documents are filed in the correct medical record.

Review of the facility's "MEDICATION ADMINISTRATION AND DOCUMENTATION" policy with a date of approval "02/2022" revealed, "...Verbal Orders/Telephone Orders...for medication shall be given only to a Nurse, or a licensed pharmacist by a person lawfully authorized to prescribe and shall be recorded promptly in the patient medical record, noting the name of the person giving the telephone order and signature of the individual receiving the order. The prescriber shall countersign the medication order within (48) hours..."

Review of the facility's "SECLUSION" policy with a reviewed date of "09/2021" revealed, "...Seclusion may only be ordered by a psychiatrist and only for the management of violent or self -destructive behavior that jeopardizes the immediate physican safety of the patient. a staff member, or others after less restrictive interventions are ineffective or ruled-out...A trained registered nurse may initiate seclusion in the absence of a practitioner...The order shall indicate the reason and maximum duration of the seclusion..."

Review of the facility's "Observation, Patient" policy with a reviewed date of "12/2020" revealed, " ...Documentation of Observations ...Staff documents all levels of observations on each patient's observations form which becomes a part of the patient record. Each entry is to include the following ...level of Observation ...Precaution ...Location ...Behavior ...Activity ...Time ...Staff Initial Signature ...During the rounds, staff are to ...Make direct visual contact; look for signs of danger or distress ...Observe the patient's environment for potential hazards that can be corrected ...belongings that were not returned to storage, etc. [and so on] ..."

2. Medical record review revealed Patient #2 was admitted to the facility on 12/1/2021 with admitting diagnoses which included Schizoaffective Disorder, Bipolar Type.

(a) Review of the Physician Telephone Orders revealed the following:
A telephone order dated 12/30/2021 at 1:00 PM revealed an order for Seclusion with the reason being for aggression. There was no documentation of the maximum duration of the seclusion.

A telephone order dated 12/31/2021 at 8:00 AM revealed an order for Seclusion without a reason for the Seclusion or maximum duration of the seclusion.

A telephone order dated 1/26/2022 at 3:00 PM revealed a telephone order for a Urinalysis. There was no documentation the physician had signed this order.

A telephone order dated 2/11/2022 at 10:45 AM revealed a telephone order for
Acyclovir to 800 milligrams (mg) by mouth three times a day for 10 days and Abreva for five days. The order did not state what the Acyclovir was being ordered to treat. (This medication is used to treat genital herpes); or what the Abreva was used to teat. (This medicine is used to treat Herpes Simplex).
The telephone order was also for Toradol 30 mg intramuscular daily for 5 days. There was no documentation what the Toradol was being ordered to treat.(Toradol is used to treat moderate to severe pain).
The three (3) telephone orders were not signed by the physician.

A telephone order dated 2/28/2022 at 5:20 PM revealed an order for Seclusion due to harming self and others. There was no documentation of the maximum duration of the seclusion. The telephone order was unsigned by a physician.

A telephone order dated 3/31/2022 at 2:00 PM revealed an order for Seclusion for four (4) hours due to aggression. The telephone order is unsigned by the physican.

A telephone order dated 3/31/2022 at 6:00 PM revealed an order for Geodon (antipsychotic) 20 mg intramuscular twice a day as needed for agitation/aggression. The telephone order was unsigned by the physician.

A telephone order dated 4/3/2022 at 8:40 PM reveal an order for Patient #2 to be transferred to the Emergency Room. This telephone order was unsigned by the Practitioner.

(b) Review of the Psychiatry progress notes Patient #2 revealed the following:
The Psychiatry progress notes dated 12/3/2021, 12/30/2021, 1/9/2022, 1/21/2022 and 1/24/2022 in Patient #2's medical record had no verification of patient identification on the progress notes.

The Psychiatry progress notes dated 12/31/2021 revealed the only patient identifier for Patient #2 was the first name hand written in cursive at the top right of the page. Patient #2's first name was misspelled.

The Psychiatry progress notes dated 1/14/2022 and 1/19/2021 revealed an illegible written name at the top of the progress note.

A Practitioner order sheet dated 3/22/2022 at 3:21 in Patient #2's medical record revealed no verification of patient identification on the order sheet.

(c) Review of the Patient Observation forms revealed:
The Patient Observation form for Patient #2 dated 4/3/2022 revealed from 6:15 PM - 8:00 PM Patient #2 was in the activity room;
At 8:15 PM, Patient #2 was at the nursing station;
From 8:30 PM - 9:00 PM Patient #2 was in the activity room; and
From 9:15 PM - 11:45 PM Patient #2 was in her room, calm and reading/music.

Review of an Emergency Medical Services (EMS) report dated 4/3/2022 revealed the EMS were at the facility at 8:18 PM to transport Patient #2 to an acute care hospital and departed the facility with Patient #2 at 8:51 PM. Patient #2 did not return to the facility until 4/3/2022 at 11:45 PM.

Review of the nursing progress notes on 4/3/2022 at 11:45 PM revealed, " ...Patient #2 returned to hospital via ambulance documentation of CT [medical imaging technique used in radiology] scan facial shows no acute fractures to face or jaw ..."

3. Medical record review revealed Patient #4 was admitted to the facility on 3/14/2022 with a diagnoses which included Bipolar Disorder Current Episode Depressed, Severe, without Psychotic Features.

A telephone order dated 3/30/22 at 1:25 PM revealed an order Benadryl 50 mg intramuscular every 6 hours as needed, Ativan 2 mg intramuscular every 6 hours as needed and Haldol 5 mg intramuscular. This telephone order was unsigned by the Practitioner.

Review of the Medication Consent - Psychotropics form dated 3/14/2022 in Patient #4's medical record revealed no verification of patient identification label on the form.

A Interdisciplinary Treatment Plan Update - Treatment Team/Conference Date page one dated 3/29/2022 in Patient #4's medical record revealed no documentation of patient identification on the form.

A Interdisciplinary Treatment Plan Update - Nursing page 3 dated 4/4/2022 at 12:00 PM in Patient #4's medical record revealed no documentation of patient identification on the form.

4. Medical record review revealed Patient #5 was admitted to the facility on 3/26/2022 with a diagnoses that included Schizoaffective Disorder, Bipolar Type.

Review of the Interdisciplinary Treatment Plan Master Sheet dated 3/26/2022 (Staff signatures of those involved in the Treatment Plan and Physician Approval of the Treatment Plan) revealed no signatures for nursing or the physician.

Based on the review of the Portable Radiological Service Agreement, medical record review and interview, the facility failed to ensure radiological services were available for a routine xray of the mandible for 1 of 5 (Patient #2) sampled patients.

The findings include:

1. Review of the facility's Portable Radiological Services Agreement (Xray and Ultrasound) dated "6/5/2019" revealed, " ...Non-STAT services: Provider shall provide a qualified Technologist who shall perform non-STAT (routine) imaging exams as requested. Every effort will be made to complete a routine exam the day it is ordered facility will be notified and the exam will be performed the next day".

2. Medical record review revealed Patient #2 was admitted to the facility on 12/1/2021 with admitting diagnoses which included Schizoaffective Disorder, Bipolar Type.

Review of the consultation report on 4/2/2022 revealed, "...Examination date of 4/2/2022 (date of incident 3/31/2022) ...Reason for consultation c/o [complaint of] jaw/facial pain on L [Left] face reports she got punched ...chief complaint my face hurts on L [left] side ...Finding and History of present illness ...L [Left] jaw/ L [Left] side face swollen ...tender ..."

Review of the practitioner order sheet on 4/2/2022 at 2:18 PM revealed an order for one Xray of the Left Mandible with a diagnoses of swelling of the Left jaw and jaw pain after a fight.

Review of the nursing assessment on 4/2/2022 at 9:00 PM revealed that Patient #2 had inquired about the xray and was notified by the nursing staff that the xray had been rescheduled for the following day.

Review of the nursing assessment dated 4/3/2022 at 11:45 AM revealed the Left jaw was swollen.

Review of the investigation report dated 4/4/2022 by Detective #1 who was assigned the case at the facility where the local police had dispatched to documented, "...Upon arrival made contact with the victim [Patient #2] ...[Patient #2] informed officers that she had been punched in the left side of her face two days ago. Nurse #2 further informed me that a service had been scheduled to come take x-rays of Patient #2 jaw yesterday and today, but they had failed to show up...".

Interview on 4/7/2022 beginning at 10:45 AM the Director of Risk Management stated, "...The altercation with [Patient #2] and [Patient #3] happened in the lunch room on Friday Afternoon [4/1/2022], [Patient #2] was complaining of jaw pain, the physician was called and an x-ray was ordered on Saturday [4/2/2022] to be completed by Sunday [4/3/2022]...The facility did not send [the patient] out for an xray when it happen because nothing was broken, no bruising and she was able to chew and swallow..."

Based on policy review, medical record review and interview, the facility failed to ensure the structure and content of the individual patient's record was an accurate functional representation of the treatment, and treatment goals, and provided sufficient evidence of the effects of the interventions for 2 of 6 (Patient #2 and #5) sampled patients for review.

The findings include:

1. Review of the facility's "Treatment Planning" policy with a reviewed date of "12/2020" revealed, "...Each patient's treatment shall be guided by the interdisciplinary treatment plan...The nursing staff is responsible for developing the Initial Treatment Plan...The treatment plan shall identify mental health and physical problems and specify those to be addressed during the treatment episode...The treatment plan shall identify goals related to each problem...Goals are based upon the assessments...Treatment plan goals shall be modified and resolved as treatment progresses...The treatment plan shall identify interventions developed to assist the patient in achieving the goals...Treatment plan updates shall be documented at least weekly... physician and treatment team assess the patient's current clinical status, review progress toward goals and make necessary modifications..."

2. Medical record review revealed Patient #2 was admitted to the facility on 12/1/2021 with admitting diagnoses which included Schizoaffective Disorder, Bipolar Type.

The Initial Nursing treatment plan dated 12/1/2021 at 3:00 PM revealed Patient #2 goal stated, "...Patient will have a [symbol for decreased] in mania/aggression... Intervention...Monitor of overt symptoms of Aggression and provide support and redirection...Set limits with patient, offering choices of appropriate options..."

The Interdisciplinary Treatment Plan Master dated 12/1/2021 revealed no documentation of physician interaction with developing the treatment plan or a signature of the physician approving the treatment plan.

The Interdisciplinary Treatment Plan Psychiatric Problem section with an initiated date of 12/3/2021 revealed Patient #2 had a problem with self harm. There were no goals or interventions for self harm.

Interview on 4/12/2022 with the Director of Risk Management was asked if self harm should have been listed as a problem on the Initial Treatment Plan. The DRM stated, "...Yes..."

The Interdisciplinary Treatment Plan Update sheet revealed no updates for the following weeks: 12/26/2021, 1/2/2022, 1/9/2022, 1/16/2022, 1/30/2022, 2/6/2022, 2/13/2022, 2/20/2022, 2/27/2022, 3/6/2022 and 4/3/2022.

2. Patient #4 presented to the facility with impulsive and inappropriate behavior on 3/14/2022.

The Initial Treatment Plan was not done on admission (3/14/2022) for Patient #4.

Interview on 5/9/2022 with the Director of Risk Management revealed no initial treatment plan had been completed for Patient #4 on admission.

Review of the Interdisciplinary Treatment Plan Update sheet revealed no updates for the following weeks: 3/21/2022; 4/11/2022; 4/25/2022; 5/2/2022 and 5/9/2022.

3. Patient #5 presented to the facility with disturbed thought attempting to harm self and staff at previous facility.

The Interdisciplinary Treatment Plan Master Sheet dated 3/26/2022 revealed no signatures for nursing or the physician.

Based on policy review, medical record review and interview, the facility failed to ensure each patients' treatment plan identified and addressed mental health and physical problems; and realistic goals and interventions were developed and implemented for those problems; and reviewed and revised as necessary but at least weekly to determine progress towards the goals for two (2) of six (6) (Patient #2) sampled patients.

The findings include:

1. Review of the facility's "Treatment Planning" policy with a reviewed date of "12/2020" revealed, "...Each patient's treatment shall be guided by the interdisciplinary treatment plan...The nursing staff is responsible for developing the Initial Treatment Plan no later that 12 hours of admission... The treatment plan shall be completed no later that the third day after admission...The treatment plan shall identify mental health and physical problems and specify those to be addressed during the treatment episode...The treatment plan shall identify goals related to each problem...Goals are based upon the assessments and are realistic, relevant, measurable and individualized, and consistent with the therapy prescribed by the psychiatrist and medical practitioner...Treatment plan goals shall be modified and resolved as treatment progresses...The treatment plan shall identify interventions developed to assist the patient in achieving the goals...Treatment plan updates shall be documented at least weekly, as the physician and treatment team assess the patient's current clinical status, review progress toward goals and make necessary modifications...Guidelines for documentation of the interdisciplinary treatment plan...Inpatient...3 days...Update Inpatient...minimally every 7 days..."

2. Medical record review revealed Patient #2, was admitted to the facility on 12/1/2021 with admitting diagnoses which included Schizoaffective Disorder, Bipolar Type.

Review of the Initial Treatment Plan - Nursing dated 12/1/2021 at 3:00 PM revealed an identified problem was the patient displayed Anger/Aggression. The Goal - "...Patient will have a [symbol for decreased] in mania/aggression...Intervention...Monitor for overt symptoms of Aggression and provide support & [and] redirection...Set limits with patient, offering choices of appropriate options..." Under section titled Medical problems listed asthma, hypertension and seizures. There was no documentation of goals or interventions for the medical problems.

Review of the Interdisciplinary Treatment Plan Master Sheet dated 12/1/2021 revealed no documentation of physician interaction or approval of the treatment plan.

Review of the Treatment Plan Psychiatric Problem Sheet with an initiated date of 12/3/2021 revealed, "...Short Term Goals...Goal #1...Patient #2 comply with medication 7 days per week to increase mood stability and Goal #2 Patient #2 identify relationship aggression and self harm identify behaviors with response interventions...Target date 12/9/2021...Updated Date 1/26/2022...Updated Date 3/16/2022 and 3/23/2022. Long term goals...Patient #2 will identify triggers for self harm and physical aggression. she will commit to utilizing learn coping skills...with a Target Date 12/10/2021...Updated Date 1/26/2022...Updated Date 3/16/2022..." There was no documentation the identified problem of self-harm was added to the Initial Interdisciplinary Treatment Plan. There was no documentation of updated goals or interventions only the "dates" that the plan was updated..

In an interview on 4/12/2022 beginning at 1:16 PM the Director of Risk Management was asked if self harm should have been listed as a problem on the Initial Treatment Plan. The DRM stated, "...Yes..."

Review of the Interdisciplinary Treatment Plan Update sheet revealed no updates for the following weeks:
12/26/2021
1/2/2022
1/9/2022
1/16/2022
12/30/2022
2/6/2022
2/13/2022
2/20/2022
2/27/2022
3/6/2022
4/3/2022

In an interview on 4/18/2022 beginning at 12:05 PM the Director of Risk Management was asked how often should updates be done on the Interdisciplinary Treatment Plan Update sheets and the Director stated, "...At least weekly."

2. Medical record review revealed Patient #4 was admitted to the facility on 3/14/2022 with a diagnoses which included Bipolar Disorder, Current Episode Depressed, Severe, without Psychotic Features.

There was no documentation an Initial Treatment Plan had been completed.

In an interview on 5/9/2022 beginning at 2:03 PM in the chapel with the Director of Risk Management (DRM) the DRM was asked is there a Initial Treatment Plan on Patient #4. The DRM stated, "...I looked and I did not find one..."

Review of the Interdisciplinary Treatment Plan Update sheet for Patient #4 revealed no documentation of updates for the following weeks:
3/21/2022;
4/11/2022;
4/25/2022;
5/2/2022 and
5/9/2022.

3. Medical record review revealed Patient #5 was admitted to the facility on 3/26/2022 with a diagnoses that included Schizoaffective Disorder, Bipolar Type.

Review of the Interdisciplinary Treatment Plan Master Sheet dated 3/26/2022 revealed no signatures for nursing or the physician.