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

1. A complete review of medical information was conducted by intake staff to appropriately screen for admission criteria, for one patient (Patient 1) (A 144);

2. The physician was notified and the observation level was increased after an incident of patient to staff assault in accordance with facility policy and procedure, for one patient (Patient 3) (A 144);

3. The appropriate frequency of monitoring was provided in accordance with the facility's policy and procedure for one patient (Patient 37) who was assessed as high risk for suicide (A 144);

4. The appropriate level of observation was provided after multiple incidents of increased aggression and patient to patient abuse, for one patient (Patient 1) (A 145);

5. The patient was separated from the perpetrator after an incident of patient to patient assault to prevent further abuse, for one patient (Patient 2) (A 145);

6. The plan of care was updated to include the use of chemical restraints, for two patients (Patients 10 and 33) (A 166);

7. The patients' conditions were monitored when restraints were implemented, for three patients (Patients 33, 10, and 14) (A 175);

8. The patients were seen face-to-face within one hour after restraints were applied, for two patients (Patients 33 and 14) (A 178);

9. The patients were seen face-to-face within one hour after restraints were applied for physical and behavioral assessments and assessment of the patients' response to the intervention, for two patients (Patient 33 and 14) (A 179);

10. Performance improvement activities included indicators to track incidents of patient to patient abuse and patient to staff attacks (A 283);

11. Performance improvement activities included indicators to track delays or omissions of physician ordered laboratory tests (A 283);

12. There were adequate numbers of staff in accordance with patient acuities (a measurement of the intensity of nursing care needed by patients) for multiple dates, shifts, and nursing units (A 392);

13. Phlebotomists and charge nurses were not included in the assigned unit staffing when their roles and responsibilities delayed their immediate availability for patient assessments and care (A 392);

14. Laboratory orders were completed in a timely manner, for six patients (Patients 11, 14, 34, 35, 36, and 37) (A 392);

15. The registered nurse signed the documentation of safety observations, for one patient (Patient 37) (A 395);

16. The care plan was updated after Patient 2 sustained skin injuries from a patient to patient assault, for one patient (Patient 2) (A 396);

17. Patient 34 was informed when a medication error occurred after he was administered a second dose of Invega Sustenna (antipsychotic medication) (A 398);

18. Patient 34's medication order, written on October 18, 2021, was noted by the licensed nurse and a 24-hour chart check was conducted on the patient's record which resulted in a medication error (A 398);

19. Patient 35's medication order, written on October 22, 2021, was noted timely by the licensed nurse and a 24-hour chart check was conducted on the patient's record which resulted in a medication error (A 398);

20. Patients 32 and 36's Clinical Institute Withdrawal Assessment (CIWA, a tool which provided detailed and evidence-based measures for alcohol withdrawal status) were conducted as ordered by the physician and in accordance with the facility's P&P (A 398);

21. Medications were administered as ordered by the physician, for seven patients (Patients 10, 2, 22, 34, 35, 36, and 39) (A 405);

22. Assessment and evaluation of the effectiveness of the treatment were conducted when as needed (PRN) medications were administered, for four patients (Patients 5, 6, 7, and 34) (A 405);

23. The 24 hour check of licensed practitioners' orders were implemented, for two patients (Patients 11 and 13) (A 405);

24. The location where the medication was administered via intramuscular injection was documented, for one patient (Patient 13) (A 405);

25. The written medication orders were complete and accurate, for one patient (Patient 13) (A 405);

26. The medications administered were documented on the medication administration record (MAR), for one patient (Patient 3) (A 405);

27. The medications were poured for each patient individually and documentation of the medications administered were conducted after each medication was dispensed to the patient (A 405);

28. Hand hygiene was implemented during the medication pass (A 405);

29. Medications were administered as prescribed and in accordance with the facility's P&P, for one of three observed patients (Patient 39) (A 405);

30. Lantus (a long acting insulin to treat high blood sugar in diabetic patients, a high alert medication) was administered with two nurses to prevent dosing errors of high alert medications in accordance with the facility's P&P (A 405);

31. A physician's order was obtained and education regarding the medication was provided to the patient prior to the patient self administering Flonase (an inhaler which could relieve sneezing, itchy nose, and nasal congestion), for one patient (Patient 11) (A 412);

32. The patients' medical records were accurately written, for two patients (Patients 32 and 35) (A 438);

33. The Medication Administration Record accurately reflected the time the medication was administered to the patients (A 438);

34. There were legible printed names and signatures for staff members providing care and administering medications, for eight patients (Patients 6, 7, 32, 33, 34, 35, 39, 40) (A 450);

35. Full informed consent was obtained for patients or their guardians, particularly those who were administered psychotropic (drug affecting how the brain works) medications, for five patients (Patient 23, 25, 27, 29, and 32) (A 466);

36. The informed consent right for a Spanish speaking patient and the opportunity to understand and consent to care was provided to the patient or his guardian in their language as guaranteed, for one patient (Patient 27) (A 466);

37. The physician orders for tests, medications, and the required observations of patients experiencing chemical detoxification and alcohol withdrawal were complete and authenticated, for six patients (Patients 17, 21, 23, 24, 26, and 32) (A 467);

38. The medication order override reports were reviewed daily to accurately process all new medications orders for pharmacist clinical review, identify new medication orders not faxed to the pharmacy, and update patient medication profiles in the computer system and Omnicell (ADDS, automated drug dispensing system) (A 490);

39. The daily pharmacist remote medication order processing was maintained, as indicated by the facility policy and procedure during the hours the pharmacy was closed to keep current the patients' medication profile in the pharmacy system and Omnicell (A 490);

40. A significant increase in the number of daily Omnicell medication overrides in October 2021 compared to the previous months was prevented (A 490);

41. Policy and procedure was developed and implemented in accordance with the accepted standards of practice for high-risk, high-alert medications to reduce serious medication errors (A 491);

42. Accounting records of controlled substances (CS) accessed from the Omnicell was in place to prevent potential abuse or diversion of CS as evidenced by missing documentation of patient assessment prior to and administration of CS (A 494);

43. A safe process for dispensing medication was implemented when the Pharmacist delivered the second dose of Invega Sustenna (antipsychotic medication) to be administered to Patient 34 without a physician's order;

44. The clinical review of medication orders during pharmacy after-hours consistent with the standards of practice was performed by the pharmacists (A 500);

45. Multiple unusable and expired CS scheduled II to V stored in the pharmacy CS cabinet were not available for patient use (A 505);

46. The initial multidisciplinary treatment plan was reviewed with the patient and/or the physician approved the treatment plan, and a follow-up treatment plan for the patient was conducted in accordance with the facility's P&P, for five patients (Patients 33, 34, 35, 36, and 40) (A 1640);

47. The patient and/or their physician signed and acknowledged the interdisciplinary treatment plan, for three patients (Patients 11, 14, and 2) (A 1644);

48. Complete and attested discharge summaries with patient final diagnoses and final care plans which were required within fifteen days of discharge, for eight patients (Patient 16, 18, 22, 23, 24, 25, 26, and 27) (A 1671);

49. There was adequate staffing when one patient (Patient 10) was placed in four point restraints (when both legs and arms were restrained) (A 1704); and,

50. A Social Worker (SW) debriefed one patient (Patient 2), after two incidents of assault by another patient in accordance with the facility's policy and procedure (P&P) (A 1715).

The cumulative effect of these systemic problems resulted in the failure to ensure the governing body was effective in carrying out its responsibilities for the conduct of the facility.

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

1. A complete review of medical information was conducted by intake staff to appropriately screen for admission criteria, for one patient (Patient 1) (A 144);

2. The physician was notified and the observation level was increased after an incident of patient to staff assault in accordance with facility policy and procedure, for one patient (Patient 3) (A 144);

3. The appropriate frequency of monitoring was provided in accordance with the facility's policy and procedure for one patient (Patient 37) who was assessed as high risk for suicide (A 144);

4. The appropriate level of observation was provided after multiple incidents of increased aggression and patient to patient abuse, for one patient (Patient 1) (A 145);

5. The patient was separated from the perpetrator after an incident of patient to patient assault to prevent further abuse, for one patient (Patient 2) (A 145);

6. The plan of care was updated to include the use of chemical restraints, for two patients (Patients 10 and 33) (A 166);

7. The patients' conditions were monitored when restraints were implemented, for three patients (Patients 33, 10, and 14) (A 175);

8. The patients were seen face-to-face within one hour after restraints were applied, for two patients (Patients 33 and 14) (A 178); and

9. The patients were seen face-to-face within one hour after restraints were applied for physical and behavioral assessments and assessment of the patients' response to the intervention, for two patients (Patient 33 and 14) (A 179).

The cumulative effect of these systemic problems resulted in the facility's failure to ensure the rights of patients at the facility were promoted and protected.

Based on interview and record review, the facility failed to ensure:

1. A complete review of medical information was conducted by intake staff to appropriately screen for admission criteria, for one patient (Patient 1) (A 144);

2. The physician was notified and the observation level was increased after an incident of patient to staff assault in accordance with facility policy and procedure, for one patient (Patient 3) (A 144); and

3. The appropriate frequency of monitoring was provided in accordance with the facility's policy and procedure for one patient (Patient 37) who was assessed as high risk for suicide (A 144).

These failures had the potential to result in patients receiving care in an unsafe setting, possibly resulting in patients suffering injury or death.

Findings:

1. During a concurrent interview and record review on November 1, 2021, at 2:30 p.m., conducted with the Director of Admissions (DOA), Patient 1's record was reviewed.

Patient 1's "Psychiatric Evaluation," dated September 30, 2021, indicated Patient 1 was admitted to the facility on September 29, 2021, with diagnoses that included bipolar disorder (mental illness marked by extreme shifts in mood) and autism spectrum disorder (developmental disability which could cause significant social, communication, and behavioral challenges for the patient).

Patient 1's "Inquiry Report Form," dated September 29, 2021, at 12:35 p.m., indicated the DOA received Patient 1's information and communicated with the referring facility.

The following intake documents for Patient 1 from the referring facility were reviewed with the DOA:

- Patient 1's "Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement For Evaluation and Treatment," dated September 23, 2021, indicated, "...(Patient 1) pulled out a chunk of her mother's hair...Diagnosed autistic, bipolar, intermittent explosive behavior, borderline psychotic w/ (with) mental age of 10..."

- The referring facility's progress notes, dated September 26, 2021, indicated, "...(Patient 1) has lived in residential treatment centers for the last 4 (four) years and has required 1:1 (one staff continuously observing one patient), sometimes 2:1 (two staff continuously observing 1 patient) observation since childhood..."

- The referring facility's progress notes, dated September 28, 2021, indicated, "many hospitals have already rejected (Patient 1) for various reasons...inpatient psychiatric unit is oftentimes not the ideal placement for patients who are on the spectrum (autism spectrum disorder) as units often are not equipped for these patients' needs in terms of therapy or staffing..."

The DOA stated he received Patient 1's intake documents by fax from the referring facility on September 29, 2021. The DOA stated he was the intake nurse who reviewed Patient 1's intake documents prior to calling the physician for admission to the facility. The DOA stated intake documents were reviewed to assess the appropriateness for admission to the facility.
The DOA stated he overlooked the above information on the intake documents. The DOA stated due to the oversight, the above information was not relayed to the physician.

The DOA further stated if he was aware of Patient 1's mental age of 10 and the needs of 1:1 and 2:1 observation, the screening process would have stopped and the physician would not have been called for acceptance or admission of Patient 1.

During an interview on October 27, 2021, at 1:35 p.m., conducted with Registered Nurse (RN) 5, RN 5 stated Patient 1 was a special needs patient, developmentally delayed, and child-like. RN 5 stated Patient 1 was unpredictable and aggressive, and was creating an unsafe environment for both Patient 1 and the other patients around her.

During an interview on October 29, 2021, at 10:30 a.m., conducted with RN 4, RN 4 stated most of the aggressive and assaultive incidents on the unit involve the developmentally delayed patients. RN 4 stated there was no specific training or inservices provided by the facility for the special care required for patients who were developmentally delayed.

During an interview on October 29, 2021, at 3 p.m., conducted with the Medical Director (MD), the MD stated there had been a few challenging cases regarding admissions of developmentally delayed patients, including Patient 1. MD 1 stated the admitting physician was not fully informed of the patient's developmental status prior to accepting the patient for admission.

During an interview on October 29, 2021, at 3:55 p.m., conducted with Social Worker (SW) 1, SW 1 stated Patient 1 required more individualized behavioral therapy than could be provided at the facility due to her developmental delay. SW 1 stated the facility did not have the resources to meet Patient 1's unique needs.

During a review of the facility's P&P titled, "Adult Inpatient Psychiatric Admission Critera," revised in August 2019, the P&P indicated, "...Intake staff will review all medical information received from referral sources prior to accepting the patient to be sure the patient is medically cleared...Clinical indicators for those patients not meeting admission criteria include...Patients who are cognitively impaired to a degree that they cannot benefit from services..."

During a review of the facility's P&P titled, "Intake Assessment Process," revised in August 2019, the P&P indicated, "...All patients presenting to (name of facility) for treatment will have an Intake screening done by admission or nursing staff. The Intake Screen documents all pertinent information regarding the patient's history prior to and leading up to patients' admission..."

2. During a concurrent interview and record review, on October 30, 2021, at 10:35 a.m., conducted with RN 4, Patient 3's record was reviewed. Patient 3 was admitted to the facility on October 28, 2021, with a diagnosis of schizophrenia (serious mental disorder in which people interpret reality abnormally).

Patient 3's "Inpatient Admission Orders," dated October 28, 2021, at 2:30 a.m., indicated Patient 13 was placed on suicide and assault precautions and every 15 minutes observation.

The nursing notes, dated October 28, 2021, at 2:41 a.m., indicated, "...(Patient 3) was signing safety contract (admission document) before abruptly stabbing staff member's head c (with) pen. Incident was unprovoked and spontaneous. (Patient 3) was separated from staff member...(Patient 3) unable to contract for safety. (Patient 3) refusing to cooperate with assessment..."

RN 4 stated she was unable to find documentation indicating the physician was immediately notified or if the level of observation was immediately increased after Patient 3's assaultive incident with a staff member on October 28, 2021, at 2:41 a.m.

RN 4 stated the physician should have been notified and the level of observation should have been increased immediately after the unprovoked assault incident.

RN 4 stated she was the nurse caring for Patient 3 during the day shift (7 a.m. to 7 p.m.) on October 28, 2021. RN 4 stated Patient 3 continued on the minimum level of observation, which was every 15 minutes, until she spoke to the physician her shift. RN 4 stated she discussed the assaultive incident with the physician while he was on the unit to see Patient 3 that evening and the physician appeared shocked. RN 4 stated the physician ordered to increase Patient 3's observation monitoring to every five minutes once he was made aware of the incident.

The physician's telephone order, dated October 28, 2021, at 6:45 p.m., indicated, "...Order: Q5 (every five) minute observation...Indication/Rationale: assaultive behavior with staff member..." (16 hours later).

During an interview on October 30, 2021, at 12:45 p.m., conducted with the Director of Performance Improvement and Risk (DPIR), the DPIR reviewed the internal incident report from Patient 3's attack of staff member. The DPIR stated the incident report did not indicate the physician was notified after the occurence.

During a review of the facility's P&P titled, "Assault Precautions," revised in September 2019, the P&P indicated, "...During hospitalization, all patients will be assessed and observed for behavior which may increase potential for assaultive behavior...Any changes in behavior or events which may impact on a patient's potential for assaultive behavior are to be reported to the Charge Nurse. The Charge Nurse will assess the patient and contact the attending/covering physician to communicate the change in behavior. The physician shall order observation and precautions consistent with the assessed level of risk..."

During a review of the facility's P&P titled, "Precautions and Observations of Patients," revised October 2020, the P&P indicated, "...to provide a safe and secure environment for patients during their hospitalization. Levels of observation can be initiated by nursing staff and are accompanied by a physician order when a patient may be considered to be at increased risk for harm to self, others...The licensed nurse or physician should determine the level of risk associated with each new admission and throughout their hospitalization on the basis of past behavior, present situation and current mental status...During the course of treatment, any qualified mental health/medical professional (as determined by the facility) may determine that intensified patient supervision is warranted and clinically necessary...Special Precaution Levels ...include...Observation 1:1...staff accompaniment (at arm's length) is required at all times...Observation on an every 15 or 5 (five) minutes...All patients should receive a minimum of every 15-minute observation..."



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2. During a concurrent interview and record review, on November 1, 2021, at 9:42 a.m., conducted with Charge Nurse (CN) 1, Patient 37's record was reviewed. The "History and Physical" indicated Patient 37 was admitted to the facility on October 27, 2021, with a chief complaint of "the patient (Patient 37) had a plan to walk into traffic..."

The "Psychiatric Evaluation," dated October 28, 2021, indicated, "...Chief Complaint...'I wanted to die by getting hit by a semi (truck)'...Justification for Hospitalization...Dangerous to self...with need for controlled environment..."

The "Inpatient Admission Orders," dated October 27, 2021, indicated, "...Suicidal Risk Level...HIGH (Level according to the...Suicide Risk Assessment)...Observation...Q (every) 15 (minutes) (MD [Physician] Justification if Moderate/High SRA [Suicidal Risk Assessment])..."

The "Patient Observations (Q15)," dated October 27, 2021, indicated Patient 37's every 15 minutes check was started on October 27, 2021, at 11:15 a.m., and continued throughout the patient's stay in the facility.

The "Nursing Reassessment," dated October 27, 2021, indicated the RN from night shift (7 p.m. to 7 a.m.) assessed Patient 37 to have current suicidal ideation.

There was no documented evidence the physician had justification for q15 minutes observation ordered for Patient 37, who was high risk for suicide.

CN 1 stated all patients in the facility would be monitored and checked q15 minutes. CN 1 stated when a patient's risk for suicide was moderate or high, the patient's frequency for monitoring would be increased to q5 minutes.

CN 1 stated when a patient with moderate or high risk for suicide was put on q15 minutes monitoring, the physician should include justification why the patient was not monitored more frequently.

CN 1 stated Patient 37, who was a high risk for suicide, should be on a minimum of q5 minutes monitoring to ensure Patient 37's safety.

During a review of the facility's P&P titled, "Suicide Risk Assessment," revised in March 2021, the P&P indicated, "...Suicide risk assessments occur at prescribed frequencies and as indicated by the patient's clinical and/or behavioral presentation...

The psychiatric practitioner shall order Precautions for Suicide and Level of Observation consistent with the assessed level of risk..."

During a review of the facility's P&P titled, "Precautions and Observations of Patients," revised in October 2020, the P&P indicated, "...The licensed nurse or physician should determine the level of risk associated with each new admission and throughout their hospitalization on the basis of past behavior, present situation and current mental status...

An order for the appropriate level of observation and precautions should be documented in the physician's order section of the medical record, and the Rounds Sheet should be initiated by the charge nurse or designee..."

Based on interview and record review, the facility failed to ensure:

1. The appropriate level of observation was provided after multiple incidents of increased aggression and patient to patient abuse, for one patient (Patient 1) (A 145); and

2. The patient was separated from the perpetrator after an incident of patient to patient assault to prevent further abuse, for one patient (Patient 2) (A 145).

These failures resulted in the development of an unsafe environment including pain and injury to Patient 2 and multiple incidents of patient to patient assault.

Findings:

1. During a concurrent interview and record review on October 27, 2021, at 1:25 p.m., conducted with Registered Nurse (RN) 2, Patient 1's record was reviewed.

The physician's telephone order, dated September 29, 2021, at 10:10 p.m., indicated Patient 1's observation level was to be monitored every five minutes.

Patient 1's "Psychiatric Evaluation," dated September 30, 2021, indicated Patient 1 was admitted to the facility on September 29, 2021, with diagnoses that included bipolar disorder (mental illness marked by extreme shifts in mood) and autism spectrum disorder (developmental disability which could cause significant social, communication, and behavioral challenges to the patient).

The physician's order, dated September 30, 2021, at 10:45 a.m., indicated Patient 1's observation level was decreased to every 15 minutes.

The "Seclusion/Restraint Packet," dated October 4, 2021, at 12:10 p.m., indicated Patient 1 was physically and chemically restrained. The packet further indicated, "...Purpose: Threat to immediate physical safety of others...(Patient 1) is highly agitated, threatening staff, throwing food tray @ (at) staff grabbing/spitting @ staff...swinging at staff...continues to be hostile/aggressive towards staff..."

The "Seclusion/Restraint Packet," dated October 5, 2021, at 11:45 a.m., indicated Patient 1 was physically and chemically restrained. The packet further indicated, "...Purpose: Threat to immediate physical safety of others...(Patient 1 was in group when she verbally attacked a peer and threw crayons at her. Incident was unprovoked...(Patient 1) was escorted to her room where she attempted to kick at staff..."

The "Interdisciplinary Plan Update," dated October 7, 2021, indicated, "...(Patient 1) impulsively will attack others...needs constant redirection..."

The "Seclusion/Restraint Packet," dated October 10, 2021, at 4 p.m., indicated Patient 1 was physically, mechanically, and chemically restrained. The packet further indicated, "...Purpose: Threat to immediate physical safety of others...(Patient 1) stood up and grabbed pts (patient's) hair...would not let go of pts hair. Staff assisted to remove (Patient 1's) hands off of pts hair and (Patient 1) then spit in staff's face...then bit staff on hand...cont. (continued) to try to hit and kick staff..."

The "Seclusion/Restraint Packet," dated October 11, 2021, at 1 p.m., indicated Patient 1 was physically and chemically restrained. The packet further indicated, "...Purpose: Threat to immediate physical safety of others...(Patient 1) bit staff...spitting on staff; tried to hit staff, swinging at staff..."

The "Seclusion/Restraint Packet," dated October 20, 2021, at 2:50 p.m., indicated Patient 1 was physically and chemically restrained. The packet further indicated, "...Purpose: Threat to immediate physical safety of others...(Patient 1) came out of her room...began spitting at staff and throwing items at staff...attempting to kick staff..."

The "Seclusion/Restraint Packet," dated October 22, 2021, at 1:40 p.m., indicated Patient 1 was physically and chemically restrained. The packet further indicated, "...Purpose: Threat to immediate physical safety of others...At approximately 1330 (1:30 p.m.)...staff was alerted when male patient yelled and found (Patient 1) on top of him biting his arm..."

The "Seclusion/Restraint Packet," dated October 23, 2021, at 5:30 p.m., indicated Patient 1 was physically and chemically restrained. The packet further indicated, "...Purpose: Threat to immediate physical safety of others...(Patient 1) charged out of room at another patient in attempt to hurt him. Staff intervened, (Patient 1) grabbed staff by the wrist and tried to bite...aggressive and danger to others..."

There was no documented evidence indicating Patient 1's level of observation was increased after any of the above assaultive behavior incidents.

RN 2 stated she was the current nurse assigned to Patient 1 and was aware of Patient 1's continued assaultive behavior. RN 2 stated Patient 1's level of monitoring has been every 15 minutes since September 30, 2021.

RN 2 stated the observation monitoring level was never increased for Patient 1 after any of her assaultive behavior incidents.

During an interview on October 29, 2021, at 5:45 a.m., conducted with RN 5, RN 5 stated if a patient's behavior was continuously aggressive, the safest level of observation would be 1:1 (one staff member to one patient).

During an interview on October 29, 2021, at 10:35 a.m., conducted with RN 6, RN 6 stated 1:1 observation would be appropriate for patients that were continuously aggressive and a danger to others.

RN 6 stated she was aware of Patient 1's aggressive behaviors and the only way to protect others would be for her to be monitored 1:1.

During a review of the facility's policy and procedure (P&P) titled, "Assault Precautions," revised in September 2019, the P&P indicated, "...During hospitalization, all patients will be assessed and observed for behavior which may increase potential for assaultive behavior...The Charge Nurse will assess the patient and contact the attending/covering physician to communicate the change in behavior...The physician shall order observation and precautions consistent with the assessed level of risk..."

During a review of the facility's P&P titled, "Precautions and Observations of Patients," revised October 2020, the P&P indicated, "...to provide a safe and secure environment for patients during their hospitalization. Levels of observation can be initiated by nursing staff and are accompanied by a physician order when a patient may be considered to be at increased risk for harm to self, others...The licensed nurse or physician should determine the level of risk associated with each new admission and throughout their hospitalization on the basis of past behavior, present situation and current mental status...During the course of treatment, any qualified mental health/medical professional (as determined by the facility may determine that intensified patient supervision is warranted and clinically necessary...Special Precaution Levels ...include...Observation 1:1...staff accompaniment (at arm's length) is required at all times...Observation on an every 15 or 5 (five) minutes...All patients should receive a minimum of every 15-minute observation..."

2. During a concurrent observation and interview, on October 27, 2021, at 10:55 a.m., conducted with Patient 2, Patient 2 was observed to have two semicircular shaped reddened areas to his right forearm. Patient 2 stated a female patient had bit him a few days prior, but he was unsure of the exact date.

During a concurrent interview and record review, on October 29, 2021, at 10:05 a.m., conducted with RN 4, Patient 2's record was reviewed.

Patient 2 was admitted to the facility on October 12, 2021, with a diagnosis of schizophrenia (serious mental disorder in which people interpret reality abnormally).

The nursing notes, dated October 22, 2021, at 10:15 a.m., indicated, "...At approximately 0950 (9:50 a.m.) patient was sitting in hallway...female patient charged at (Patient 2) in order to harm him...managed to scratch (Patient 2) underneath L (left) eye and indent teeth on head...Medical doctor was called and ordered to clean wound and apply Neosporin (an antibacterial medication used to prevent infection)..."

The nursing notes, dated October 22, 2021, at 1:30 p.m., indicated, "(Patient 2) was in tv (television) room when he began yelling...found female patient on (Patient 2), female patient was removed from (Patient 2). It was noted (Patient 2) had a bite mark to the right lower arm...(Patient 2) to be transferred to unit 3. (Patient 2) was transferred at 1400 (2 p.m.)...pain at the bite site..."

RN 4 stated she was the nurse assigned to Patient 2 during the day shift of October 22, 2021, when Patient 2 was assaulted twice by the same female patient, at 9:50 a.m., and again at 1:30 p.m, on one of the the facility's units.

RN 4 stated neither Patient 2 nor the assaultive female patient were transferred to a different unit after the first assault that occurred on October 22, 2021, at 9:50 a.m.

RN 4 stated Patient 2 was transferred to another unit after the second assault that occurred on October 22, 2021, at 1:30 p.m.

During an interview on October 27, 2021, at 1:25 p.m., conducted with RN 2, RN 2 stated after any patient to patient abuse, the patients should be separated and one of the patients should be transferred to another unit immediately.

During a review of the facility's policy and procedure (P&P) titled, "Patient to Patient Assault," revised in May 2021, the P&P indicated, "...To provide a safe and secure environment for all patients and staff...When an assaultive behavior has been identified assigned staff, if needed, will ensure the patient remains at a distance of ten (10) feet from other patients. This includes groups, meal times, and outdoor activities..."

Based on interview and record review, the facility failed to ensure the plan of care was updated to include the use of chemical restraints, for two patients (Patients 10 and 33).

These failures had the potential to impact the patients' achievement of their overall individualized goals during the recovery process.

Findings:

1. A review of Patient 10's record was conducted. Patient 10 was admitted to the facility on October 18, 2021, on a 5150 hold (a 72 hour involuntary hold) as the patient was deemed to be gravely disabled. Patient 10 was diagnosed with schizophrenia (a mental disorder involving a breakdown in the relation between thought, emotion, and behavior leading to withdrawal from reality).

A review of the Seclusion/Restraint packet, dated October 18, 2021, at 8:45 p.m., indicated Zyprexa (medication used to treat mood and behavior in patients diagnosed with schizophrenia) 10 milligrams (mg), was administered intramuscularly (IM, injection into a muscle) to Patient 10.

A review of the "Progress Notes," dated October 18, 2021, at 9 p.m., indicated at 8:30 p.m., Patient 10 was in the hallway, pacing anxiously, throwing paper into the hall, and yelling threats at the staff and the physician.

A review of the "Progress Notes," dated October 19, 2021, at 7:15 a.m., indicated at 6:58 a.m., Patient 10 yelled, charged and pushed a staff against the wall. A code white (a method to call for a staff response when a violent or potentially violent person becomes unmanageable and presents as a danger to self or others) was subsequently called.

A review of the "Seclusion/Restraint Packet," dated October 19, 2021, at 7:15 a.m., indicated the following medications were administered to Patient 10:

- Haldol (medication used for treatment of mental disorder) 10 mg IM, one time (x 1);

- Ativan (a sedative medication) 2 mg IM x 1; and,

- Benadryl (could be used to treat anxiety with sedative effect) 50 mg IM x 1.

There was no documented evidence Patient 10's care plan was updated to address Patient 10's need for a chemical restraint.

There was no documented evidence Patient 10's care plan was updated to address the patient's need for a chemical restraint.

An interview was conducted with Registered Nurse (RN) 4, on October 29, 2021, at 11 a.m., who after reviewing Patient 10's record stated the patient's care plan should have been updated after receiving a chemical restraint.



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2. During a concurrent interview and record review, on November 2, 2021, at 2:09 p.m., conducted with Charge Nurse (CN) 1, Patient 33's record was reviewed. The "Initial Psychiatric Evaluation" indicated Patient 33 was admitted to the facility on October 12, 2021, for a 5150 due to grave disability.

The "Medication Administration Record," indicated Patient 33 was administered the following medications on October 25, 2021, at 7:35 p.m.:

- Haldol 5 mg IM one time (x 1);

- Ativan 2 mg IM x 1; and

- Benadryl 50 mg x 1.

The "Progress Notes," dated October 25, 2021, indicated, "...At approx (approximately) 1920 (7:20 p.m.) Pt (Patient 33) became agitated and started yelling in the hallway threatening staffed (sic)...Doctor notified and order was given Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM now. Pt was assisted to his room and was (sic) comply c (with) the medication..."

There was no documented evidence Patient 33's care plan was updated addressing Patient 33's need for a chemical restraint.

CN 1 stated the combination of Haldol, Ativan, and Benadryl, when given to the patient IM, was considered a chemical restraint.

CN 1 stated when a patient was put on a restraint, the patient's care plan should address the need of restraint on the patient.

CN 1 stated Patient 33's care plan should have been updated addressing the patient's need for a chemical restraint.

During a review of the facility policy and procedure (P&P) titled, "Seclusion and Restraint of Patient," revised in September 2019, was conducted. The P&P indicated, "...The treatment plan shall be reviewed and revised following the first episode of chemical restraint to include measures to prevent recurrence. Additional review of the treatment plan,with revision as indicated, will occur if the patient is chemically restrained on more than one occasion..."

Based on interview and record review, the facility failed to ensure the patients' conditions were monitored when restraints were implemented, for three patients (Patients 33, 10, and 14).

These failures had the potential to result in inappropriate, unnecessary, and prolonged use of restraints, and in the violation of the patient's rights.

Findings:

1. During a concurrent interview and record review, on October 29, 2021, at 8:15 a.m., conducted with the Director of Nursing (DON), Patient 33's record was reviewed. The "Initial Psychiatric Evaluation" indicated Patient 33 was admitted to the facility on October 12, 2021, for a 5150 (a person involuntarily detained for a 72-hour) due to grave disability.

The "Medication Administration Record," indicated Patient 33 was administered the following medication on October 25, 2021, at 7:35 p.m.:

- Haldol (medication used for treatment of mental disorder) 5 milligram (mg) intramuscularly (IM, injection in the muscle) one time (x 1);

- Ativan (a sedative medication) 2 mg IM x 1; and

- Benadryl (can be used to treat anxiety with sedative effect) 50 mg x 1.

The "Progress Notes," dated October 25, 2021, indicated, "...At approx (approximately) 1920 (7:20 p.m.) Pt (Patient 33) became agitated and started yelling in the hallway threatening staffed...Doctor notified and order was given Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM now. Pt was assisted to his room and was (sic) comply c (with) the medication..."

There was no documented evidence Patient 33's condition was monitored when the patient received the medications mentioned above.

The DON stated the combination of Haldol, Benadryl, and Ativan, when administered to a patient by IM, would be considered a chemical restraint. The DON stated when a chemical restraint was used, the patient's condition should be monitored.

The DON stated the monitoring of the patient on chemical restraints should be documented on the restraint monitoring packet.

The DON stated there was no restraint monitoring packet completed when Patient 33 received chemical restraints on October 25, 2021. The DON stated Patient 33's condition was not monitored when the patient received chemical restraints.

The DON stated the RN should follow the policy and procedure when administering chemical restraints to a patient.



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2. A review of Patient 10's record was conducted. Patient 10 was admitted to the facility on October 18, 2021, on a 5150 hold as the patient was deemed to be gravely disabled. Patient 10 was diagnosed with schizophrenia (a mental disorder involving a breakdown in the relation between thought, emotion, and behavior leading to withdrawal from reality).

A review of the "Progress Notes," dated October 19, 2021, at 6:58 a.m., indicated Patient 10 yelled and charged at staff, and pushed the staff against the wall. Further record review indicated a code white (a method to call for a staff response when a violent or potentially violent person became unmanageable and presented a danger to self or others)was called.

A review of the "Seclusion/Restraint Packet," dated October 19, 2021, at 7 p.m., indicated Patient 10 was placed in four point restraints (a restraint that immobilized all four extremities which could be used for violent behaviors).

A review of the "Seclusion/Restraint Packet," dated October 19, 2021, at 7:15 a.m. indicated Patient 10 received:

- Haldol 10 mg IM x 1;

- Ativan 2 mg IM x 1; and

- Benadryl 50 mg IM x 1.

A review of the "Patient Monitoring" document indicated interventions for four point restraints were to include discussing release criteria, offering fluids (minimum hourly), taking vital signs (minimum every 30 minutes for chemical restraints), offering elimination (minimum every two hours), and conducting range of motion every two hours, along with a circulation check (every 15 minutes) were required.

Patient 10 remained in four point restraints from 7 a.m., until 9:15 a.m. (two hours and 15 minutes.) The record reflected that vital signs were done once, when the chemical restraint was administered, at 7:15 a.m.

An interview was conducted with Registered Nurse (RN) 4, on October 29, 2021, at 11:15 a.m. RN 4 stated after reviewing Patient 10's record the documentation failed to show release criteria were discussed, fluids were offered, vital signs were done more than once, elimination was offered, and range of motion was done every two hours after the four point restraints were placed along with checking the patient's circulation in his arms and legs.

3. A review of Patient 14's record was conducted. Patient 14 was admitted to the facility on October 6, 2021, with a diagnosis of a mood disorder.

A review of the "Progress Notes," dated October 18, 2021, at 4 p.m., indicated Patient 14 was to be transferred to a higher level of care. As the patient was placed on the stretcher, the patient became "combative, hit the stretcher, threw her pillow, and postured toward the (ambulance) staff." The physician was notified and a chemical restraint which consisted of Zyprexa (a medication used to treat anxiety),10 milligrams (mg) Intramuscularly (IM), and Benadryl (a medication which may be used for its sedative effects) 50 mg IM, was ordered to be "administered now."

Further record review failed to show that a seclusion/restraint packet was implemented.

An interview was conducted with Registered Nurse (RN) 4, on October 29, 2021, at 11:30 a.m. RN 4 stated after reviewing Patient 14's record, a seclusion/restraint packet was not completed to show the patient's reaction to the medication.

A review of the facility policy and procedure titled, "Seclusion and Restraint of Patient (Revised: 9/2019)," was conducted. The care for the patient receiving chemical restraints indicated, "...Vital signs will be taken immediately following administration of the medication and then minimum every 30 minutes times two. If the emergency episode exceeds one hour, vital signs will continue to be taken every 30 minutes through the duration of the emergency episode. The practitioner will be notified immediately if the vital signs are abnormal..."

The care of the patient in seclusion/restraints indicated, "...All patients in restraint or seclusion are assessed and their needs addressed by a Registered Nurse at the initiation of restraint or seclusion and every 15 minutes thereafter. This assessment includes: Vital Signs, injury assessment, nutrition/hydration assessment, circulation and range of Motion, Hygiene and Elimination, Physical and Psychological Status Assessment De-Escalation Interventions and the need for Continued Containment..."

Based on interview and record review, the facility failed to ensure the patients were seen face-to-face within one hour after restraints were applied, for two sampled patients (Patients 33 and 14).

These failures resulted in the patients to not have an in-person evaluation and assessment of the patients' physical and psychological status after restraints were applied.

Findings:

1. During a concurrent interview and record review, on October 29, 2021, at 8:15 a.m., conducted with the Director of Nursing (DON), Patient 33's record was reviewed. The "Initial Psychiatric Evaluation" indicated Patient 33 was admitted to the facility on October 12, 2021, for a 5150 (a person to be involuntarily detained for 72-hour) due to grave disability.

The "Progress Notes," dated October 25, 2021, indicated, "...At approx (approximately) 1920 (7:20 p.m.) Pt (Patient 33) became agitated and started yelling in the hallway threatening staffed...Doctor notified and order was given Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM now. Pt was assisted to his room and was (sic) comply c (with) the medication..."

The "Medication Administration Record," indicated Patient 33 was administered the following medications on October 25, 2021, at 7:35 p.m.:

- Haldol (medication used for treatment of mental disorder) 5 milligram (mg) intramuscularly (IM, injection in the muscle) one time (x 1);

- Ativan (a sedative medication) 2 mg IM x 1; and,

- Benadryl (can be used to treat anxiety with sedative effect) 50 mg x 1.

There was no documented evidence Patient 33 was seen face-to-face by a physician or other licensed provider, or by a trained registered nurse, within one hour after the patient was given the IM medications (Haldol, Benadryl, and Ativan).

The DON stated the combination of Haldol, Benadryl, and Ativan, when administered IM to a patient, would be considered a chemical restraint. The DON stated the patient should have a face-to-face evaluation within one hour after the restraint was applied.

The DON stated the face-to-face evaluation of the patient should be documented on the restraint monitoring packet.

The DON stated there was no restraint monitoring packet completed when Patient 33 received a chemical restraint on October 25, 2021. The DON stated Patient 33 was not seen face-to-face within one hour after the patient received chemical restraints.

The DON stated the RN should follow the policy and procedure when administering chemical restraints to a patient.



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2. A review of Patient 14's record was conducted. Patient 14 was admitted to the facility on October 6, 2021, with a diagnosis of a mood disorder.

A review of the "Progress Notes," dated October 18, 2021, at 4 p.m., indicated Patient 14 was to be transferred to a higher level of care. As she was placed on the stretcher, the patient became "combative, hit the stretcher, threw her pillow and postured toward the (ambulance) staff."

The physician was notified and a chemical restraint which consisted of Zyprexa (a medication used to treat anxiety) 10 mg IM and Benadryl 50 mg IM were ordered to be administered at that time.

Further record review failed to show that a seclusion/restraint packet was implemented or that a one hour face to face evaluation was conducted.

An interview was conducted with Registered Nurse (RN) 4, on October 29, 2021, at 11:30 a.m. RN 4 stated after reviewing Patient 14's record, that a seclusion/restraint packet was not completed.

A review of the facility policy and procedure titled, "Seclusion and Restraint of Patient (Revised: 9/2019)," was conducted. The purpose was to provide guidelines for patient monitoring and care in order to promote patient safety, protection, and to maintain the patients rights and dignity. To ensure that restraint and/or seclusion procedures conform with all accreditation standards and State and Federal regulations and to guarantee all patients their human and civil rights.

The policy further indicated, "A licensed Independent Practitioner or trained Registered Nurse shall conduct an inperson evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status. This in person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention."

Based on interview and record review, the facility failed to ensure the patients were seen face-to-face within one hour for physical and behavioral assessments and assessment of the patient's response to the intervention after restraints were applied, for two patients (Patient 33 and 14).

These failures resulted in the patients to not have an in-person physical and behavioral evaluation and assessment of the patient's response to the intervention with a potential for a delay in necessary treatment and further intervention.

Findings:

1. During a concurrent interview and record review, on October 29, 2021, at 8:15 a.m., conducted with the Director of Nursing (DON), Patient 33's record was reviewed. The "Initial Psychiatric Evaluation" indicated Patient 33 was admitted to the facility on October 12, 2021, for a 5150 (a person involuntarily detained for a 72-hour period) due to grave disability.


The "Progress Notes," dated October 25, 2021, indicated, "...At approx (approximately) 1920 (7:20 p.m.) Pt (Patient 33) became agitated and started yelling in the hallway threatening staffed...Doctor notified and order was given Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM now. Pt was assisted to his room and was (sic) comply c (with) the medication..."

The "Medication Administration Record," indicated Patient 33 was administered the following medications on October 25, 2021, at 7:35 p.m.:

- Haldol (medication used for treatment of mental disorder) 5 milligram (mg) intramuscularly (IM, injection in the muscle) one time (x 1);

- Ativan (a sedative medication) 2 mg IM x 1; and,

- Benadryl (can be used to treat anxiety with sedative effect) 50 mg x 1.

There was no documented evidence Patient 33 was seen face-to-face by a physician or other licensed provider, or by a trained registered nurse, within one hour after the patient was given the IM medications (Haldol, Benadryl, and Ativan) to evaluate the patient's immediate situation, reaction to the intervention, and medical and behavioral condition.

The DON stated the combination of Haldol, Benadryl, and Ativan, when administered IM to a patient, would be considered a chemical restraint. The DON stated the patient should have a face-to-face evaluation within one hour after the restraint was applied.

The DON stated the face-to-face evaluation of the patient should be documented on the restraint monitoring packet.

The DON stated there was no restraint monitoring packet completed when Patient 33 received a chemical restraint on October 25, 2021. The DON stated Patient 33 was not seen face-to-face within one hour after the patient received chemical restraints.

The DON stated the RN should follow the policy and procedure when administering chemical restraints to a patient.



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2. A review of Patient 14's record was conducted. Patient 14 was admitted to the facility on October 6, 2021, with a diagnosis of a mood disorder.

A review of the "Progress Notes" dated October 18, 2021 at 4 p.m., Patient 14 was to be transferred to a higher level of care. As Patient 14 was placed on the stretcher the patient became "combative, hit the stretcher, threw her pillow and postured toward the (ambulance) staff." The physician was notified and a chemical restraint which consisted of Zyprexa (used to treat anxiety),10 milligrams (mg) Intramuscularly (IM), and Benadryl (can be used for its sedative effects) 50 mg IM was ordered to be "administered now."

Further record review failed to show that a seclusion/restraint packet was implemented, or that a one hour face to face evaluation of the patient's immediate situation, reaction to the intervention, and medical and behavioral condition, and the need to continue or terminate the restraint was conducted.

An interview was conducted with Registered Nurse (RN) 4, on October 29, 2021, at 11:30 a.m. RN 4 stated after reviewing Patient 14's record, that a seclusion/restraint packet was not completed.

A review of the facility policy and procedure titled, "Seclusion and Restraint of Patient (Revised: 9/2019)," was conducted. The purpose was to provide guidelines for patient monitoring and care in order to promote patient safety, protection, and to maintain the patients rights and dignity. To ensure that restraint and/or seclusion procedures conform with all accreditation standards and State and Federal regulations and to guarantee all patients their human and civil rights.

The policy further indicated, "A licensed Independent Practitioner or trained Registered Nurse shall conduct an inperson evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status. This in person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention."

Based on interview and record review, the facility failed to ensure performance improvement activities included indicators to track:

1. Incidents of patient to patient abuse and patient to staff attacks (A 283); and

2. Delays or omissions of physician ordered laboratory (lab) tests (A 283).

The cumulative effect of these failures resulted in the facility to not identify areas of needed improvement in patient care, placed patients at increased risk of receiving care in an unsafe environment, and delayed care and treatment.

Based on interview and record review, the facility failed to ensure performance improvement activities included indicators to track:

1. Incidents of patient to patient abuse and patient to staff attacks (Cross refer A 144 and A 145).

This failure resulted in incidents involving assaultive patients to not be monitored and an increased potential for patient abuse and a violation of patient's rights.

2. Delays or omissions of physician ordered laboratory (lab) tests (Cross refer A 392).

This failure resulted in delays in patient care and treatment.

Findings:

1. During a concurrent interview and record review, on November 3, 2021, at 11:10 a.m., conducted with the Director of Performance Improvement and Risk (DPIR), the internal incident report data and the facility's 2021 performance improvement meeting minutes were reviewed.

The internal incident report data indicated the following:

- There were six incidents of patient to patient abuse between June 27, 2021, and October 22, 2021.

- There were 21 incidents of patient to staff attacks between March 25, 2021, and October 28, 2021.

The facility's 2021 performance improvement meeting minutes did not indicate data on patient to patient abuse or patient to staff attacks were being reviewed, discussed, and/or monitored by the facility.

The DPIR stated information on patient to patient abuse or patient to staff attacks were not included in the facility's Quality Committee meetings.

On November 3, 2021, at 2:15 p.m., representatives from the Quality Committee were interviewed. During the interview, the Chief Executive Officer (CEO) stated there was no data or quality indicators for the review of patient to patient assaults or patient to staff attacks included in the performance improvement program. The CEO stated a discussion of these incidents was an area that needed improvement.

2. During the survey, six sampled patients (Patients 11, 14, 34, 35, 36, and 37) were identified with incomplete or delayed implementation of lab orders.

During an interview on November 2, 2021, at 3:50 p.m., conducted with the Director of Nursing (DON), the DON stated she was unaware of any data the facility was tracking for delayed or omitted lab orders.

On November 3, 2021, at 2:15 p.m., representatives from the Quality Committee were interviewed. During the interview, the DON stated the facility had not identified patient lab omissions and delays as an issue to be discussed in the Quality Committee.

The facility's document titled, "(Facility's name) 2020 Process Improvement Annual Report and Evaluation," was reviewed. The document did not indicate patient to patient assaults, patient to staff assaults, or laboratory collection data were included in the process improvement team activities.

The facility's document titled, "Process Improvement Program," revised in February 2020, indicated, "...The program emphasizes ongoing assessment of the dimensions of performance, including surveillance of health care delivery...the outcomes of care and services delivered, the availability and utilization of support resources...

Objectives are...

To support effective systems and a learning environment in the pursuit of zero harm...

To enhance, maintain, and continually improve the quality of patient care through intra- and/or interdepartmental/service measurement and assessment of patient care, resolution of problems, and ongoing pursuit of opportunities to improve patient care...

To facilitate a proactive approach of continuous and robust process improvement...

To achieve an effective reduction of medical/health care errors and other factors that contribute to unintended adverse patient outcomes..."

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

1. There were adequate numbers of staff in accordance with patient acuities (a measurement of the intensity of nursing care needed by patients) for multiple dates, shifts, and nursing units (A 392);

2. Phlebotomists and charge Nurses (CN) were not included in the assigned unit staffing when their roles and responsibilities delayed their immediate availability for patient assessments and care (A 392);

3. Laboratory orders were completed or implemented in a timely manner, for six patients (Patients 11, 14, 34, 35, 36, and 37) (A 392);

4. The registered nurse signed the documentation of safety observations, for one patient (Patient 37) (A 395);

5. The care plan was updated after Patient 2 sustained skin injuries from a patient to patient assault, for one patient (Patient 2) (A 396);

6. Patient 34 was informed when a medication error occurred after he was administered a second dose of Invega Sustenna (an antipsychotic medication) (A 398);

7. Patient 34's medication order, written on October 18, 2021, was noted by the licensed nurse and a 24-hour chart check was conducted on the patient's record which resulted in a medication error (A 398);

8. Patient 35's medication order, written on October 22, 2021, was noted timely by the licensed nurse and a 24-hour chart check was conducted on the patient's record which resulted in a medication error (A 398);

9. Patients 32 and 36's Clinical Institute Withdrawal Assessment (CIWA, a tool which provided detailed and evidence-based measures for alcohol withdrawal status) were conducted as ordered by the physician and in accordance with the facility's policy and procedure (A 398);

10. Medications were administered as ordered by the physician, for six patients (Patients 10, 2, 22, 34, 35, and 36) (A 405);

11. Assessment and evaluation of the effectiveness of the treatment were conducted when as needed (PRN) medications were administered, for four patients (Patients 5, 6, 7, and 34) (A 405);

12. The 24 hour check of licensed practitioners orders were implemented, for two patients (Patients 11 and 13) (A 405);

13. The location where the medication was administered via intramuscular injection (IM, injection into the muscle) was documented, for one patient (Patient 13) (A 405);

14. The written medication orders were complete and accurate, for one patient (Patient 13) (A 405);

15. The medications administered were documented on the medication administration record (MAR), for one patient (Patient 3) (A 405);

16. The medications were poured for each patient individually and documentation of the medications administered were conducted after each medication was dispensed to the patient (A 405);

17. Hand hygiene was implemented during the medication pass (A 405);

18. Medications were administered as prescribed in accordance with the hospital policies and procedures, for one of three observed patients (Patient 39) (A 405);

19. Lantus (a long acting insulin to treat high blood sugar in diabetic patients, a high alert medication) was administered with two nurses to prevent dosing errors of high alert medications in accordance with the policy and procedure (A 405); and

20. A physician's order was obtained and education regarding the medication was provided prior to the patient self administering Flonase (an inhaler which could relieve sneezing, itchy nose, and nasal congestion), for one patient (Patient 11) (A 412).

The cumulative effect of these systemic problems resulted in patients to not be provided safe and quality care to meet their needs.

Based on interview and record review, the facility failed to ensure:

1. There were adequate numbers of staff in accordance with patient acuities (a measurement of the intensity of nursing care needed by patients) for multiple dates, shifts, and nursing units;

2. Phlebotomists (trained staff who would draw blood for laboratory tests) and charge nurses (CN) were not included in the assigned unit staffing when their roles and responsibilities delayed their immediate availability for patient assessments and care; and

3. Laboratory orders were completed or implemented in a timely manner, for six patients (Patients 11, 14, 34, 35, 36, and 37).

These failures had the potential to result in the patients' needs not being met, a delay in treatment, and an overall risk to the quality of patient care.

Findings:

1. During a concurrent interview and record review, on November 1, 2021, at 9:50 a.m., conducted with CN 1, staff assignments and patient acuities were reviewed. CN 1 stated patient acuities were completed by the registered nurses (RNs) two hours before the start of the next shift. CN 1 stated the acuity number determined the same number of staff needed to care for patients on that specific unit and shift.

CN 1 stated there was not enough staff for patient care in accordance to the patient acuity for the following dates, shifts, and nursing units:

- For the night shift (7 p.m. to 7 a.m.), on October 5, 2021, the Mission unit had a patient acuity of six (six staff were needed to provide patient care) with only five staff assigned to the unit;

- For the day shift (7 a.m. to 7 p.m.), on October 7, 2021, the Arlington unit had a patient acuity of five (five staff were needed to provide patient care) with only four staff assigned to the unit;

- For the day shift, on October 8, 2021, the Arlington unit had a patient acuity of five with only three staff assigned to the unit for the entire shift;

- For the day shift, on October 9, 2021, the Arlington unit had a patient acuity of four (four staff were needed to provide patient care) with only three staff assigned to the unit the entire shift and the Magnolia unit had a patient acuity of five with only four staff assigned to the unit the entire shift;

- For the night shift, on October 9, 2021, the Magnolia unit had a patient acuity of five with only four staff assigned to the unit;

- For the night shift, on October 18, 2021, the Mission unit had a patient acuity of six with only five staff assigned to the unit;

- For the day shift, on October 22, 2021, the Arlington unit had a patient acuity of four with only three staff assigned the entire shift;

- For the day shift, on October 23, 2021, the Arlington unit had a patient acuity of four with only three staff assigned the entire shift and the Mission unit had a patient acuity of six with only five staff assigned;

- For the night shift, on October 23, 2021, the Arlington unit had a patient acuity of four with only three staff assigned, the Magnolia unit had a patient acuity of four with only three staff assigned, and the Mission unit had a patient acuity of six with only five staff assigned the entire shift;

- For the day shift, on October 25, 2021, the Arlington unit had a patient acuity of five with only four staff assigned the entire shift and the Mission unit had a patient acuity of six with only five staff assigned the entire shift;

- For the night shift, on October 25, 2021, the Arlington unit had a patient acuity of five with only four staff assigned the entire shift and the Mission unit had a patient acuity of six with only four staff assigned the entire shift;

- For the day shift, on October 28, 2021, the Magnolia unit had a patient acuity of six with only five staff assigned the entire shift;

- For the night shift, on October 28, 2021, the Arlington unit had a patient acuity of five with only four staff assigned and the Mission unit had a patient acuity of six with only four staff assigned the entire shift;

- For the day shift, on October 29, 2021, the Arlington unit had a patient acuity of five with only four staff assigned and the Magnolia unit had a patient acuity of seven with only six staff assigned the entire shift; and

- For the night shift, on October 29, 2021, the Magnolia unit had a patient acuity of six with only five staff assigned.

During an interview on October 29, 2021, at 6 a.m., conducted with RN 7, RN 7 stated staffing was often not adequate for the number and acuity of patients on the units. RN 7 stated when staffing was short, it was physically impossible to safely care for psychiatric patients on the unit.

During a review of the facility's policy and procedure (P&P) titled, "Patient Classification/Nursing Staffing Plan," reviewed in January 2021, the P&P indicated, "...To ensure quality nursing care and safe patient environment by establishing an acuity system to determine an appropriate staffing pattern based on the assessment of patient needs...The Patient Classification Acuity form will be completed each shift by the unit RN two hours prior to the oncoming shift utilizing the guidelines on the form...The charge nurse refers to the Patient Classification Acuity form which has predetermined acuity hours appropriate for the delivery of quality nursing care...The total number of patients on each level of care is multiplied by the established number of hours, for each shift. The total number of hours will then be divided by 12 to determine the number of staff required...The necessary staffing mix will be determined by the charge nurse upon review of the patient acuity levels..."

2a. During a concurrent interview and record review, on November 1, 2021, at 9:50 a.m., conducted with CN 1, staffing schedule sheets were reviewed. The staffing schedules indicated the Behavioral Health Associate/Phlebotomist (BHAP) was included in the patient care assignment for the entire night shift (7 p.m. to 7 a.m.), on October 7 and 10, 2021.

During a concurrent interview and record review, on November 2, 2021, at 3:35 p.m., conducted with CN 1, the BHAPs timesheet for September 26, 2021, through October 23, 2021, were reviewed.

CN 1 stated the timesheet indicated the BHAP was working a full night shift and was assigned to a unit for patient care on September 26, 27, 28, and 29, 2021; and on October 7, 9, 10, 13, 14, 16, 17, 18, 19, and 20, 2021.

During a concurrent interview and record review, on November 2, 2021, at 3:50 p.m., conducted with the Director of Nursing (DON), the facility's October 2021 "Phlebotomy Schedule" was reviewed.

The schedule indicated three other staff members were scheduled to act as the phlebotomists on October 2, 3, 6, 16, and 22 - 31, 2021.

The DON stated those three staff members were also assigned to patient care for their scheduled shifts on the above dates.

The DON stated the staff members' responsibilities during those shifts would include leaving their assigned units to draw blood for the entire facility.

During an interview on November 3, 2021, at 8:30 a.m., conducted with CN 2, CN 2 stated when the BHAP was assigned as staff on the unit for night shift, the BHAP will be off the unit and unavailable for patient care between 5 a.m. and 7 a.m. CN 2 stated the BHAP would leave the unit starting at 5 a.m. to draw blood for all patients.

b. During an interview on October 29, 2021, at 11:55 a.m., conducted with CN 2, CN 2 stated he was assigned a full patient assignment and would also oversee all three units of the facility on his scheduled shifts.

During a concurrent interview and record review on November 2, 2021, at 3:50 p.m., conducted with the DON, the facility's "Charge Nurse RN Job Description," dated January 1, 2020, was reviewed. The job description indicated essential functions of the CN included the following:

- "...monitor and coordinate other nurse and members of the staff on the daily medical or behavioral health care activities of the unit...;

- Schedule staff to ensure full coverage at all times and to ensure effective application of services;

- Lead, guide, and train employees performing work;

- Oversee and provide direct nursing evaluation, consultation, and other related care to patients as required;

- Coordinate services and maintain communication with other departments or staff as required; and

- Oversee quality assurance activities and compliance to operational standards, participate in program development, development or implementation of operating policy and procedure and promote continuous improvement of workplace safety and environmental practices..."

The DON stated the CN job description was accurate in regard to the CN responsibilities.

The DON stated the CNs did have a full patient assignment in addition to the CN responsibilities.

During an interview on October 29, 2021, at 4:30 p.m., conducted with CN 1, CN 1 stated he was one of the CNs for the day shift.

CN 1 reviewed the CN job description and stated he would be unable to fulfill the CN responsibilities listed if he was providing direct care to patients and had a patient assignment.

CN 1 stated there was extra help on day shift from directors and administration to assist in overseeing the three units when he was assigned patients, but night shift and weekends did not have directors onsite for assistance.



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3a. On October 30, 2021, at 9 a.m., a review of Patient 11's record was conducted. Patient 11 was admitted to the facility on October 14, 2021, with a diagnosis of schizophrenia (a mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and a withdrawal from reality).

On October 14, 2021, six laboratory (lab) diagnostic studies were ordered by the patient's physician to include a complete blood count (CBC, a blood test to provide information about the cells in a person's blood), a complete metabolic panel (CMP - a blood test used to evaluate liver function, kidney function, and nutrients level), a lipid panel (a blood test to measure fats in the body), a thyroid level (blood test to determine the thyroid hormone level), a urinalysis (UA, urine test), and a urine drug screen UDS). The ordered lab tests were not competed until October 20, 2021, with a four day delay.

An interview was conducted with the CN 1, on November 2, 2021, at 11 a.m. CN 1 stated when the physician ordered laboratory tests for the patient, the laboratory test should be completed within 24 hours.

An interview was conducted with the DON on October 30, 2021, at 11 a.m. The DON stated the lab orders were drawn late, which could cause a delay in the overall care of the patient.

b. On November 2, 2021, a review of Patient 14's record was conducted. Patient 14 was admitted to the facility on October 6, 2021, with a diagnosis of mood disorder.

On October 6, 2021, lab diagnostic studies were ordered by the patient's physician to include a CBC, a lipid panel, a thyroid level, a urinalysis and a urine drug screen. The CBC was not drawn and the remainder of the lab studies were not drawn until four days later on October 10, 2021.

An interview was conducted with the CN 1, on November 2, 2021, at 11 a.m. CN 1 stated when the physician orders laboratory tests for the patient, the laboratory test should be completed within 24 hours

An interview was conducted with the Director of Nurses (DON) on October 30, 2021, at 11 a.m. The DON stated the lab orders were drawn late, which could cause a delay in the overall care of the patient.



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c. During a concurrent interview and record review, on November 2, 2021, at 11 a.m., conducted with CN 1, Patient 34's record was reviewed. The "History and Physical" indicated Patient 34 was admitted to the facility on October 17, 2021, for psychiatric treatment.

The record indicated on October 17, 2021, a physician's telephone order was received for Patient 34 to have a laboratory test for CBC, CMP, lipid panel, thyroid stimulating hormone (TSH, a blood test to measure thyroid hormones), urinalysis, UDS, and Depakote level (the amount of valproic acid, an anti-seizure medication, in the blood).

The laboratory test result indicated Patient 34's blood test was collected on October 20, 2021 (three days after the laboratory test was ordered) for the CBC, CMP, lipid panel, TSH, and Depakote level.

There was no documented evidence Patient 34's UA and UDS tests were completed.

The "Practitioner Order Set," dated October 23, 2021, indicated the physician ordered Patient 34 to have an anemia (a blood disorder) panel test.

The laboratory test result indicated Patient 34's blood test was collected on October 26, 2021 (three days after the laboratory test was ordered) for the anemia panel.

The "Practitioner Order Set," dated October 28, 2021, indicated, "...Pls (Please) add to lab (laboratory test for Patient 34) Iron, TIBC (total iron-binding capacity), Ferritin (a blood protein in the body that contained iron), B12 (a blood test to measure the amount of vitamin B12 in the body)..."

The "Diagnostic Lab Collection & (and) Refusal Log" indicated Patient 34 refused blood tests for Iron, TIBC, Ferritin, and B12 on November 1, 2021 (four days after the laboratory tests were ordered).

CN 1 stated there was a delay in completing Patient 34's blood test. CN 1 stated Patient 34's blood test should have been done within 24 hours after it was ordered.

CN 1 stated there was no documented evidence a requisition was completed for Patient 34's UA and UDS tests as ordered by the physician on October 20, 2021. CN 1 stated if there was no requisition made, then Patient 34's test would not be done.

d. During a concurrent interview and record review on October 29, 2021, at 12:20 p.m., conducted with Charge Nurse (CN) 1, Patient 35's record was reviewed. The "History and Physical" indicated Patient 35 was admitted to the facility on October 12, 2021, for psychiatric treatment.

The "Practitioner Order Sheet," dated October 17, 2021, indicated for Patient 35 to have a laboratory test for CBC, CMP, lipid panel, TSH, and UA.

There was no documented evidence Patient 35's UA was completed.

CN 1 stated there was no documented evidence a requisition was completed for Patient 35's UA as ordered by the physician on October 17, 2021. CN 1 stated if there was no requisition made, then Patient 35's test would not be done.

e. During a concurrent interview and record review on November 1, 2021, at 10:10 a.m., conducted with CN 1, Patient 36's record was reviewed. The "History and Physical" indicated Patient 36 was admitted to the facility on October 21, 2021, for alcohol detoxification.

The "Inpatient Admission Orders," dated October 21, 2021, indicated for Patient 36 to have a laboratory test for CBC, CMP, lipid panel, TSH, UA, UDS, and lithium level (blood work to test for the level of lithium, a medication for mania, a mood disorder).

There was no documented evidence Patient 36's laboratory tests ordered by the physician on October 21, 2021, were completed.

Patient 36's "Practitioner Order Sheet," dated October 22, 2021, indicated, "...Draw blood for labs if not done already for admission orders..."

There was no documented evidence Patient 36's laboratory tests ordered by the physician on October 22, 2021, were completed.

Patient 36's "Practitioner Order Sheet," dated October 27, 2021, indicated, "...Blood draw was ordered upon admission but of not done, please order Lithium level, CMP, CBC...thyroid panel, lipid panel..."

There was no documented evidence Patient 36's laboratory tests ordered by the physician on October 27, 2021, were completed, six days after the lab tests were orderd on admission.

CN 1 stated there was no documented evidence a requisition was completed for Patient 36's laboratory tests as ordered by the physician on October 21, 22, and 27, 2021.

CN 1 stated if there was no requisition made, then Patient 36's test would not be done.

f. During a concurrent interview and record review, on November 1, 2021, at 9:42 a.m., conducted with CN 1, Patient 37's record was reviewed. The "History and Physical" indicated Patient 37 was admitted to the facility on October 27, 2021, with a chief complaint of "the patient (Patient 37) had a plan to walk into traffic..."

The "Inpatient Admission Orders," dated October 27, 2021, indicated for Patient 37 to have a laboratory test for CBC, CMP, lipid panel, TSH, UA, and UDS.

There was no documented evidence Patient 37's laboratory tests ordered by the physician on October 27, 2021, were completed.

CN 1 stated there was no documented evidence a requisition was completed for Patient 37's laboratory tests as ordered by the physician on October 27, 2021.

CN 1 stated if there was no requisition made, then Patient 37's test would not be done.

CN 1 stated when the physician ordered laboratory tests for the patient, the laboratory tests should be completed within 24 hours.

CN 1 stated it was the facility's procedure when the physician ordered the patient's laboratory test, the licensed nurse was to write the order on the laboratory requisition paper and to file it in the laboratory binder. CN 1 stated the phlebotomist would come every morning, collect the requisition paper from the binder, and would obtain the specimen from the patient for the laboratory test as indicated on the requisition paper.

During an interview on November 1, 2021, at 10 a.m., conducted with the Director of Performance Improvement and Risk Management (DPIRM), the DPIRM stated the facility had no policy on laboratory orders and ensuring the test were completed. The DPIRM stated the nurses should follow the procedure of writing a laboratory requisition for the phlebotomist when the physician ordered laboratory test for the patient.

Based on interview and record review, the facility failed to ensure the documentation of safety observations were signed by the registered nurse (RN), for one patient (Patient 37).

This failure had the potential to result in Patient 37 to receive care in an unsafe setting and may result in the patient to suffer injury or death.

Findings:

During a concurrent interview and record review, on November 1, 2021, at 10:42 a.m., conducted with Charge Nurse (CN) 1, Patient 37's record was reviewed. The "History and Physical" indicated Patient 37 was admitted to the facility on October 27, 2021, with a chief complaint of "the patient (Patient 37) had a plan to walk into traffic..."

The "Psychiatric Evaluation," dated October 28, 2021, indicated, "...Chief Complaint...'I wanted to die by getting hit by a semi (truck)'...Justification for Hospitalization...Dangerous to self...with need for controlled environment..."

The "Inpatient Admission Orders," dated October 27, 2021, indicated, "...Suicidal Risk Level...HIGH (Level according to the...Suicide Risk Assessment)...

Observation...Q (every) 15 (minutes) (MD [Physician] Justification if Moderate/High SRA [Suicidal Risk Assessment])..."

The "Patient Observations (Q15)," dated October 27, 2021, indicated Patient 37's was observed every 15 minutes and was on suicide precautions.

There was no documented evidence the physician had justification for q15 minutes observation ordered for Patient 37, who was a high risk for suicide.

There was no documented evidence the RN signed Patient 37's observation record.

CN 1 stated all patients in the facility would be monitored and checked at minimum of q15 minutes. CN 1 stated when a patient's risk for suicide was moderate or high, the patient's frequency for monitoring would be increased to q5 minutes.

CN 1 stated when a patient with moderate or high risk for suicidal was put on q15 minutes monitoring, the physician should include a justification as to why the patient was not monitored more frequently.

CN 1 stated the record should be signed by the RN to verify the patient was on the correct observation monitoring time and correct precautions.

CN 1 stated if the RN checked on Patient 37's observation record, the RN would have known the patient was on q15 minutes observation instead of q5 minutes.

CN 1 stated the RN should have informed and verified with the physician Patient 37's appropriate observation frequency.

During a review of the facility's policy and procedure (P&P) titled, "Suicide Risk Assessment," revised in March 2021, the P&P indicated, "...Suicide risk assessments occur at prescribed frequencies and as indicated by the patient's clinical and/or behavioral presentation...

The psychiatric practitioner shall order Precautions for Suicide and Level of Observation consistent with the assessed level of risk..."

During a review of the facility's P&P titled, "Precautions and Observations of Patients," revised on October 2020, the P&P indicated, "...The licensed nurse or physician should determine the level of risk associated with each new admission and throughout their hospitalization on the basis of past behavior, present situation and current mental status...

An order for the appropriate level of observation and precautions should be documented in the physician's order section of the medical record, and the Rounds Sheet should be initiated by the charge nurse or designee..."

Based on observation, interview, and record review, the facility failed to ensure the care plan was updated after Patient 2 sustained skin injuries from a patient to patient assault, for one patient (Patient 2).

This failure resulted in the potential for an increased risk of miscommunication between the healthcare team and possibly contribute to the delay in care and treatment of Patient 2's injuries.

Findings:

During a concurrent observation and interview, on October 27, 2021, at 10:55 a.m., conducted with Patient 2, Patient 2 was observed to have two semicircular shaped reddened areas to his right forearm. Patient 2 stated a female patient had bit him a few days prior, but he was unsure of the exact date.

During a concurrent interview and record review, on October 27, 2021, at 12:25 p.m., conducted with the Director of Nursing (DON), Patient 2's record was reviewed. Patient 2 was admitted to the facility on October 12, 2021, with a diagnosis of schizophrenia (a mental disorder in which the patient's thoughts were not based on reality).

The nursing notes, dated October 22, 2021, at 10:15 a.m., indicated, "...female patient charged at (Patient 2) in order to harm him...managed to scratch (Patient 2) underneath L (left) eye and indent teeth on head...Medical doctor was called and ordered to clean wound and apply Neosporin (an antibacterial medication used to prevent infection)..."

The physician's telephone order, dated October 22, 2021, at 10 a.m., indicated, "Clean wound and apply Neosporin q 12 hr (every 12 hours)..."

The nursing notes, dated October 22, 2021, at 1:30 p.m., indicated, "...(Patient 2) was in tv (television) room when he began yelling...found female patient on (Patient 2)...It was noted that (Patient 2) had a bite mark to the right lower arm...photograph taken and put in chart..."

The physician's order, dated October 23, 2021, at 12:26 p.m., indicated to give Augmentin (an antibiotic used to treat infections) orally twice a day for five days and Tdap (a combination vaccine which could protect against three life-threatening bacterial diseases).

There was no documented evidence indicating a nursing care plan for Patient 2's skin injuries, wound care, and treatment was initiated.

The DON stated she was unable to find any documentation that the Neosporin, Augmentin, and Tdap were administered to Patient 2 as ordered by the physician or that a care plan for Patient 2's wounds was initiated by the nursing staff.

The DON stated a care plan should have been initiated for Patient 2's skin injuries and treatment interventions.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Treatment Plans," revised in August 2019, the P&P indicated, "...To provide a complete, individualized, plan of care based on an integrated assessment of the patient's specific needs and problems, and prioritization of those needs...To provide appropriate communication between team members that fosters consistency and continuity of care...Treatment plans are immediately reviewed and updated for any...Patient Injury...New medical issues..."

Based on interview and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented when:

1a. There was no documented evidence Patient 34 was informed when a medication error occurred after he was administered a second dose of Invega Sustenna (antipsychotic medication).

In addition, there was no documentation on Patient 34's record regarding the medication error which occurred after the patient was administered the second dose of Invega Sustenna;

b. Patient 34's medication order, written on October 18, 2021, was not noted by the licensed nurse and a 24 hour chart check was not conducted on the patient's record which resulted in a medication error;

2. Patient 35's medication order, written on October 22, 2021, was not noted timely by the licensed nurse and a 24 hour chart check was not conducted on the patient's record which resulted in a medication error; and

3. Patients 32 and 36's Clinical Institute Withdrawal Assessment (CIWA, a tool which provided detailed and evidence-based measures for alcohol withdrawal status) were not conducted as ordered by the physician and in accordance with the facility's P&P.

These failures resulted in the unsafe provision of care and delay in treatment which may have an unfavorable effect on the patient's safety and quality of care.

Findings:

1. During a concurrent interview and record review, on October 29, 2021, at 4:10 p.m., with Charge Nurse (CN) 1, Patient 34's record was reviewed. The "History and Physical" indicated Patient 34 was admitted to the facility on October 17, 2021, for psychiatric treatment.

a. Patient 34's "Practitioner Order Sheet," dated October 22, 2021, indicated, "...on 10/25 (October 25, 2021), start Invega Sustenna 234 mg (milligram) IM (injection in the muscle) x (times) 1 (one)..."

The "Dispense Log," indicated the Pharmacist dispensed Invega Sustenna for Patient 34 on October 25, 2021, and on October 28, 2021.

The "Medication Administration Record" indicated Patient 34 was administered one dose of Invega Sustenna 234 mg IM on October 25, 2021, and another on October 28, 2021.

There was no documented evidence the physician ordered Patient 34 to have a second dose of Invega Sustenna (on October 28, 2021).

CN 1 stated Patient 34 had only one physician order of Invega Sustenna to be given on October 25, 2021.

CN 1 stated the Invega Sustenna administered to Patient 34 on October 28, 2021, did not have a physician's order. CN 1 stated it was a medication error.

CN 1 stated the nurse who administered Invega Sustenna to Patient 34 on October 28, 2021, should have checked and verified the physician's order prior to administration.

CN 1 stated when the nurse could not find the medication order for the second dose of Invega Sustenna, the nurse should have called the physician and verified if Patient 34 needed the second dose prior to administering the medication.

CN 1 stated there was no documentation on Patient 34's record regarding the medication error that occurred after the patient was administered the second dose of Invega Sustenna.

CN 1 stated there was no documentation Patient 34 was informed of the medication error that occurred after the patient was administered the second dose of Invega Sustenna.

CN 1 stated it should have been documented as indicated in the facility's P&P.

During an interview on November 1, 2021, at 12:15 p.m., with the Pharmacist, the Pharmacist stated he received a physician's order for Invega Sustenna 234 mg to be given IM once on October 25, 2021. The Pharmacist stated there was no physician's order for a second dose of Invega Sustenna for Patient 34.

The Pharmacist stated Patient 34's medication label for Invega Sustenna was printed twice. The Pharmacist stated Patient 34's duplicate label for Invega Sustenna was included in the medications he received on October 28, 2021.

The Pharmacist stated he did not verify if the Invega Sustenna for Patient 34 was dispensed on October 25, 2021, before delivering the medication to the nurse on October 28, 2021.

The Pharmacist stated it was his fault for dispensing the second dose of the Invega Sustenna to Patient 34 without a physician's order.

During a review of the facility's P&P titled, "Medication Errors/Adverse Drug Events," reviewed in July 2020, the P&P indicated, "...Several types of medication errors exist which include...Unauthorized Drug Error: Administration to the patient of medication not authorized by a legitimate prescriber for the patient...

When a medication error occurs...Notify patient and/or representative of error unless instructed by licensed practitioner. Document evidence of same...Record the medication error per facility policy..."

b. During a concurrent interview and record review, on October 29, 2021, at 11:25 a.m., conducted with CN 1, Patient 34's "Practitioner Order Sheet," dated October 18, 2021, indicated to administer the following medications:

- Risperdal (an antipsychotic medication) two milligrams (mg) by mouth (po) at night;

- Depakote (an anti-seizure medication) 500 mg po at night; and

- Trazadone (an anti-depressant and/or sedative medication) 100 mg po at night as needed for insomnia (difficulty with sleeping).

Patient 34's MAR indicated the following:

- Risperdal 2 mg po was administered on October 23, 2021, at 9 p.m. (five days after the medications was ordered); and,

- Depakote 500 mg was administered on October 25, 2021, at 9 p.m. (seven days after the medication was ordered).

There was no documented evidence the physician's order for the medications mentioned above were noted by a licensed nurse.

There was no documented evidence a 24 hour chart check was conducted from October 18 to 23, 2021.

There was no documented evidence the physician's order for the medications mentioned above were transcribed in Patient 34's Medication Administration Record (MAR) on October 18, 2021.

CN 1 stated when a physician wrote an order for the patient, the licensed nurse would sign the order to indicate the licensed nurse noted the order and would process the order.

CN 1 stated when the licensed nurse noted a medication order, the order would be faxed to the pharmacy and the pharmacy would verify and transcribe the order in the patient's MAR.

CN 1 stated a 24 hour chart check should be done by the licensed nurse at the end of the 24 hour shift to ensure all physician's orders for the day were noted and processed. CN 1 stated a 24 hour chart check should be conducted to verify all medication orders in the MAR were accurate and complete.

CN 1 stated Patient 34's physician's order for Risperdal, Depakote, and Trazadone on October 18, 2021, were not noted by the licensed nurse. CN 1 stated if the orders were not noted, the orders were not processed, and the medications were not administered as ordered by the physician to Patient 34.

CN 1 stated a 24 hour chart check was not conducted on Patient 34's record from October 18 to 23, 2021. CN 1 stated if a 24 hour check was completed, the licensed nurse would have noticed the medications ordered on October 18, 2021, were not in Patient 34's MAR.

CN 1 stated Patient 34's medication error would have been prevented if the licensed nurse reviewed and noted the physician's order and a 24 hour chart check was conducted on Patient 34's record.

CN 1 stated there was no documentation on Patient 34's record regarding the medication error which occurred when Risperdal and Depakote were not administered to the patient as ordered on October 18, 2021.

CN 1 stated there was no documentation the physician and Patient 34 were informed of the medication error which occurred when Risperdal and Depakote were not administered to the patient as ordered on October 18, 2021.

CN 1 stated it should have been documented as indicated in the facility's P&P.

2. During a concurrent interview and record review, on October 29, 2021, at 8:10 a.m., with the Director of Nursing (DON), Patient 35's record was reviewed. The "History and Physical" indicated Patient 35 was admitted to the facility on October 12, 2021, for psychiatric treatment.

Patient 35's "Practitioner Order Sheet," dated October 22, 2021, indicated to administer the following medications:

- Neosporin (antibiotic ointment) apply to bilateral (both sides) soles of feet every 12 hours for five days; and,

- Vaseline (ointment used for dry skin) apply to bilateral soles of feet once a day as needed.

The "Practitioner Order Sheet" indicated the licensed nurse noted the medication order on October 24, 2021 (two days after the medication order was written).

Patient 35's MAR, dated October 23, 2021, indicated the physician's order was transcribed as "...Neosporin to bil (bilateral) soles of feet x 5D (five days) q12 (every 12 hours) PRN (as needed)."

There was no documented evidence a 24 hour chart check was conducted on October 22 and 23, 2021.

There was no documented evidence the physician's order for the medications mentioned above were transcribed in Patient 35's Medication Administration Record (MAR) on October 22, 2021.

The DON stated the physician's medication order on October 22, 2021, was not processed timely because the licensed nurse did not note the order until two days after it was written.

The DON stated Neosporin was not transcribed in Patient 35's MAR on October 22, 2021, so it was not administered to the patient.

The DON stated when the physician's order for Neosporin was transcribed in Patient 35's MAR on October 23, 2021, it was written incorrectly. The DON stated the Neosporin order was written in the MAR as PRN and the order was to be given every 12 hours for five days.

The DON stated the Neosporin should have been administered to Patient 35 on a routine schedule as ordered by the physician.

The DON stated it was a medication error for not administering the Neosporin to Patient 35 as ordered by the physician.

The DON stated when the licensed nurse noted a medication order, the order would be faxed to the pharmacy and the pharmacy should verify and transcribe the order in the patient's MAR.

The DON stated a 24 hour chart check should be done by the licensed nurse at the end of the 24 hour shift to ensure all physician's orders for the day were noted and processed. The DON stated a 24 hour chart check should be conducted to verify all medication orders in the MAR were accurate and complete.

During a review of the facility's P&P titled, "Medication Errors/Adverse Drug Events," reviewed in July 2020, the P&P indicated, "...Several types of medication errors exist which include...Omission Error: The failure to administer an ordered dose to a patient before the next scheduled administration time...

When a medication error occurs...Notify the licensed practitioner immediately...Notify patient and/or representative of error unless instructed by licensed practitioner. Document evidence of same...Record the medication error per facility policy..."

During a review of the facility's P&P titled, "Medication Administration and Records," reviewed in July 2020, the P&P indicated, "...New medication orders and changes on medication therapy will be noted by the Registered Nurse (RN) or the Licensed Practical Nurse (LPN) on the licensed practitioner's order sheet. The notation must include their signature and military time when the order was transcribed. The original order must be faxed to the pharmacy...

New medication orders or changes in medication orders will be written on the current patient MAR...

Prior to using the MAR, a twenty-four (24) hour-check of licensed practitioner's orders compared against the computerized MAR will be performed. This will be done nightly by nursing to assure accuracy of transcription and accurate computer entry by the Pharmacy Department...If correct, the night nurse must sign as verification/reconciliation on the MAR and indicate the twenty-four (24) hour check has been completed by signing and dating the licensed practitioner order form..."

3. During a concurrent interview and record review, on October 30, 2021, at 10:15 a.m., conducted with Licensed Vocational Nurse (LVN) 4, Patient 32's record was reviewed. The "History and Physical," indicated Patient 32 was admitted to the facility on October 28, 2021, for psychiatric treatment and alcohol detoxification.

The "Inpatient Admission Orders," dated October 28, 2021, indicated, "...CIWA Assessment...CIWA Assessments Protocol until Discontinued by MD (physician) Q2hrs (every two hours) x (for) 24Hrs (24 hours); Then Q4hrs (every four hours) x 24Hrs; Then continue QShift (every shift)..."

The "Clinical Institute Withdrawal Assessment - Alcohol (CIWA -Ar) Score Sheet," indicated the following on October 28, 2021:

- At 1:25 p.m., Patient 32's CIWA was initiated.

- Patient 32's CIWA score was 11 (Patient 32's CIWA should be conducted every two hours from October 28, 2021, at 1:25 p.m., to October 29, 2021, at 1:25 p.m.); and

- There was no documented evidence Patient 32's CIWA was conducted at 3 p.m., and 5 p.m. The columns under the 3 p.m., and 5 p.m., were blank.

The "Clinical Institute Withdrawal Assessment - Alcohol (CIWA -Ar) Score Sheet," indicated the following on October 29, 2021:

- At 5:49 a.m., Patient 32's CIWA score was 10; and

- There was no documented evidence Patient 32's CIWA was conducted at 7 a.m., 9 a.m., 11 a.m., 1 p.m., and 5 p.m. (Patient 32's CIWA should be conducted every two hours from October 28, 2021, at 1:25 p.m., to October 29, 2021, at 1:25 p.m.; every four hours from October 29, 2021, at 1:25 p.m., to October 30, 2021, at 1:25 p.m.).

The columns under the times of 7 a.m., 9 a.m., 11 a.m., 1 p.m., and 5 p.m., were blank.

LVN 4 stated when a patient was admitted for alcohol detoxification, the CIWA protocol would be initiated.

LVN 4 stated the assigned medication nurse on the unit would be responsible for conducting the patient's CIWA per protocol.

LVN 4 stated there was no documentation that Patient 32's CIWA was conducted on October 28, 2021, at 3 p.m., and 5 p.m.

LVN 4 stated there was no documentation that Patient 32's CIWA was conducted on October 29, 2021, at 7 a.m., 9 a.m., 11 a.m., 1 p.m., and 5 p.m.

LVN 4 stated Patient's 32's CIWA should have been conducted every two hours for 24 hours, then every four hours for 24 hours, then every shift until the CIWA was discontinued by the physician.

4. During a concurrent interview and record review, on November 1, 2021, at 10:10 a.m., with CN 1, Patient 36's record was reviewed. The "History and Physical" indicated Patient 36 was admitted to the facility on October 21, 2021, for alcohol detoxification.

The "Inpatient Admission Orders," dated October 21, 2021, indicated, "...CIWA Assessment...CIWA Assessments Protocol until Discontinued by MD Q2hrs x 24Hrs; Then Q4hrs x 24Hrs; Then continue QShift..."

The "Clinical Institute Withdrawal Assessment - Alcohol (CIWA -Ar) Score Sheet," indicated the following on October 21, 2021:

- At 4 p.m., Patient 36's CIWA was initiated.

- Patient 36's CIWA score was 19 (Patient 36's CIWA should be conducted every two hours from October 21, 2021, at 4 p.m., to October 22, 2021, at 4 p.m.); and

- There was no documented evidence Patient 36's CIWA was conducted at 6 p.m.

The "Clinical Institute Withdrawal Assessment - Alcohol (CIWA -Ar) Score Sheet," indicated the following on October 22, 2021:

- At 6 a.m., Patient 36's CIWA was 14 (Patient 36's CIWA should be conducted every two hours from October 21, 2021, at 4 p.m., to October 22, 2021, at 4 p.m.);

- Patient 36's next CIWA was conducted at 8 p.m., (13 hours after the last CIWA). The patient's CIWA score was 13; and,

- Patient 36's next CIWA was on October 23, 2021, 9 p.m., (25 hours after the last CIWA) (Patient 36's CIWA should be conducted every four hours from October 22, 2021, at 4 p.m., to October 23, 2021, at 4 p.m.). The patient's CIWA score was 11.

CN 1 stated when a patient was admitted for alcohol detoxification, the CIWA protocol would be initiated.

CN 1 stated the assigned medication nurse on the unit would be responsible for conducting the patient's CIWA per protocol.

CN 1 stated Patient 32's CIWA should have been conducted every two hours for every two hours for 24 hours, then every four hours for 24 hours, then every shift until the CIWA was discontinued by the physician. CN 1 stated Patient 32's CIWA was incomplete and did not follow the CIWA protocol as ordered by the physician.

CN 1 stated CIWA was an important assessment tool for patients with alcohol withdrawal. CN 1 stated following the CIWA protocol would help in the patients' assessments to provide necessary interventions to help patients from experiencing alcohol withdrawal symptoms like hypertensive crisis (uncontrolled high blood pressure), seizure, tremors, and anxiety.

During a review of the facility's P&P titled, "Clinical Institute Withdrawal Assessment (CIWA) Procedure," reviewed in May 2020, the P&P indicated, "...All patients are assessed upon admission for substance abuse history. Patients admitted with a recent history of alcohol abuse will be assessed for withdrawal symptoms utilizing the CIWA..."

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

1. Medications were administered as ordered by the physician, for six patients (Patients 10, 2, 22, 34, 35, and 36);

2. Assessment and evaluation of the effectiveness of the treatment were conducted when as needed (PRN) medications were administered, for four patients (Patients 5, 6, 7, and 34);

3. The 24 hour check of licensed practitioners' orders were implemented, for two patients (Patients 11 and 13);

4. The location where the medication was administered via intramuscular injection (IM, injected to the muscle) was documented, for one patient (Patient 13);

5. The written medication orders were complete and accurate, for one patient (Patient 13);

6. The medications administered were documented on the medication administration record (MAR), for one patient (Patient 3);

7. The medications were poured for each patient individually and documentation of the medications administered were conducted after each medication was dispensed to the patient;

8. Hand hygiene was implemented during the medication pass;

9. Medications were administered as prescribed and in accordance with the hospital policies and procedures for one of three observed patients (Patient 39); and

10. Lantus (a long acting insulin to treat high blood sugar in diabetic patients, a high alert medication) was administered with two nurses to prevent dosing errors of high alert medications in accordance with the policy and procedure.

These failures resulted in medication errors, inadequate medical treatment, and a delay of treatment for the patients, which may cause harm and/or a deterioration of the patients' medical conditions.

Findings:

1a. A review of Patient 10's record was conducted. Patient 10 was admitted to the facility on October 18, 2021, with a diagnosis of schizophrenia (a mental health disorder involving a breakdown in the relation between thought, emotion, and behavior leading to withdrawal from reality). Patient 10 was discharged on October 30, 2021, at 4 p.m.

A review of Patient 10's medication administration record (MAR) was conducted. On October 27, 2021, Klonopin 0.25 milligrams was ordered to be administered orally twice daily, at 9 a.m., and 5 p.m., for anxiety and agitation.

Further review of the MAR reflected Patient 10 did not receive his 9 a.m., dose of Klonopin on October 30, 2021.

An interview was conducted with the Charge Nurse (CN) 1, on November 1, 2021, at 5 p.m. CN 1 stated medications should be administered as ordered by the physician. CN 1 verified Patient 10 missed his 9 a.m. dose of Klonopin on October 30, 2021, and stated without the medication the patient's anxiety level could increase and impact his planned discharge to home on October 30, 2021, in the afternoon.

b. During a concurrent interview and record review, on October 27, 2021, at 12:25 p.m., conducted with the Director of Nursing (DON), Patient 2's record was reviewed. Patient 2 was admitted to the facility on October 12, 2021, with a diagnosis of schizophrenia.

The nursing notes, dated October 22, 2021, at 10:15 a.m., indicated, "...female patient charged at (Patient 2) in order to harm him...managed to scratch (Patient 2) underneath L (left) eye and indent teeth on head...Medical doctor was called and ordered to clean wound and apply Neosporin (an antibacterial medication used to prevent infection)..."

The physician's telephone order, dated October 22, 2021, at 10 a.m., indicated, "Clean wound and apply Neosporin q 12 hr (every 12 hours)..."

The nursing notes, dated October 22, 2021, at 1:30 p.m., indicated, "...(Patient 2) was in tv (television) room when he began yelling...found female patient on (Patient 2)...It was noted that (Patient 2) had a bite mark to the right lower arm...photograph taken and put in chart..."

The physician's order, dated October 23, 2021, at 12:26 p.m., indicated to give Augmentin (an antibiotic used to treat infections) orally twice a day for five days and Tdap (a combination vaccine that could protect against three life-threatening bacterial diseases).

There was no documented evidence indicating Neosporin was administered to Patient 2 after October 22, 2021, at 10 a.m.

There was no documented evidence indicating Augmentin twice daily or Tdap was administered to Patient 2.

The DON stated she was unable to find any documentation that the Neosporin, Augmentin, and Tdap were administered to Patient 2 as ordered by the physician.

c. During a concurrent interview and record review, on November 3, 2021, at 1:40 p.m., conducted with CN 1, Patient 22's record was reviewed. Patient 22 was admitted to the facility on October 14, 2021, with the diagnosis of alcohol use disorder.

The physician's telephone orders, dated October 14, 2021, at 11 p.m., indicated to administer Ativan (medication used to treat anxiety) 2 mg (milligrams) by mouth every four hours as needed for a CIWA (Clinical Institute Withdrawal Assessment, clinical assessment tool used by medical professionals to assess the severity of alcohol withdrawal) score greater than or equal to eight for 48 hours.

The orders also indicated to administer Clonidine (medication to treat high blood pressure [BP]) 0.1 mg by mouth every 12 hours as needed for elevated BP greater than or equal to 160/100, to record Patient 22's BP upon initial dose and every two hours until the BP was within parameters, and to call the physician if the BP remained elevated after four hours.

Patient 22's CIWA score sheet indicated Patient 22 had a CIWA score of 10 on October 14, 2021, at 10:30 p.m., and a score of eight on October 15, 2021, at midnite. The CIWA score sheet also indicated the following BPs which were greater than 160/100:

- 187/113 on October 14, 2021, at 10:30 p.m.;

- 179/98 on October 15, 2021, at midnite;

- 182/102 on October 15, 2021, at 2 a.m.;

- 178/86 on October 15, 2021, at 4 a.m.; and,

- 182/90 on October 15, 2021, at 6 a.m.

Patient 22's medication administration record for October 14 and 15, 2021, did not have any documentation that indicated Ativan or Clonidine were administered.

CN 1 stated Patient 22 should have been given Ativan per the physician's order for the CIWA score of greater than or equal to 8 on October 14, 2021, at 10:30 p.m., or on October 15, 2021, at midnite, but there was no documentation that indicated Ativan was administered.

CN 1 further stated Patient 22 should have been given Clonidine for BPs above 160/100, but there was no documentation that Clonidine was administered.

d1. During a concurrent interview and record review, on October 29, 2021, at 4:10 p.m., conducted with CN 1, Patient 34's record was reviewed. The "History and Physical" indicated Patient 34 was admitted to the facility on October 17, 2021, for psychiatric treatment.

Patient 34's "Practitioner Order Sheet," dated October 22, 2021, indicated, "...on 10/25 (October 25, 2021), start Invega Sustenna 234 mg (milligrams) IM (injection in the muscle) x (times) 1 (one)..."

The "Dispense Log," indicated the Pharmacist dispense Invega Sustenna for Patient 34 on October 25, 2021, and October 28, 2021.

The "Medication Administration Record" indicated Patient 34 was administered one dose of Invega Sustenna 234 mg IM on October 25, 2021, and October 28, 2021.

There was no documented evidence the physician ordered for Patient 34 to have a second dose of Invega Sustenna (on October 28, 2021).

CN 1 stated Patient 34 had only one physician order of Invega Sustenna to be given on October 25, 2021.

CN 1 stated the Invega Sustenna administered to Patient 34 on October 28, 2021, did not have a physician's order. CN 1 stated it was a medication error.

CN 1 stated the nurse who administered Invega Sustenna to Patient 34 on October 28, 2021, should have checked and verified the physician's order.

CN 1 stated when the nurse could not find the medication order for a second dose of Invega Sustenna, the nurse should have called the physician and verified if Patient 34 needed the second dose prior to administering the medication.

During an interview on November 1, 2021, at 12:15 p.m., conducted with the Pharmacist, the Pharmacist stated he received a physician's order for Invega Sustenna 234 mg to be given IM once on October 25, 2021. The Pharmacist stated there was no physician's order for a second dose of Invega Sustenna for Patient 34.

The Pharmacist stated Patient 34's medication label for Invega Sustenna was printed twice. The Pharmacist stated Patient 34's duplicate label for Invega Sustenna was included on the medications he received on October 28, 2021.

The Pharmacist stated he did not verify if the Invega Sustenna for Patient 34 was dispense on October 25, 2021, before delivering the medication to the nurse on October 28, 2021.

The Pharmacist stated it was his fault for dispensing the second dose of the Invega Sustenna to Patient 34 without a physician's order.

d2. During a concurrent interview and record review, on October 29, 2021, at 11:25 a.m., conducted with CN 1, Patient 34's "Practitioner Order Sheet," dated October 18, 2021, indicated to administer the following medications:

- Risperdal (an antipsychotic medication) two milligram (mg) by mouth (po) at night;

- Depakote (an anti-seizure medication) 500 mg po at night; and

- Trazadone (an anti-depressant and/or sedative medication) 100 mg po at night as needed for insomnia (difficulty of sleeping).

Patient 34's MAR indicated the following:

- Risperdal 2 mg po was administered on October 23, 2021, at 9 p.m. (five days after the medications was ordered); and

- Depakote 500 mg was administered on October 25, 2021, at 9 p.m. (seven days after the medication was ordered).

There was no documented evidence the physician's order for Risperdal and Depakote ere transcribed in Patient 34's Medication Administration Record (MAR) on October 18, 2021.

CN 1 stated when a physician wrote an order for the patient, the licensed nurse would sign the order to indicate the licensed nurse noted the order and would process the order.

CN 1 stated when the licensed nurse noted a medication order, the order would be faxed to the pharmacy and the pharmacy would verify and transcribe the order in the patient's MAR.

CN 1 stated Patient 34's physician's order for Risperdal, Depakote, and Trazadone on October 18, 2021, were not noted by the licensed nurse. CN 1 stated if the orders were not noted, the orders were not processed and the medications were not administered to Patient 34 as ordered by the physician.

CN 1 stated a 24 hour chart check was not conducted on Patient 34's record from October 18 to 23, 2021. CN 1 stated if a 24 hour check was completed, the licensed nurse would have noticed the medications ordered on October 18, 2021, were not in Patient 34's MAR.

CN 1 stated Patient 34's medication error would have been prevented if the licensed nurse reviewed and noted the physician's order, and a 24 hour chart check were conducted on Patient 34's record.

d3. During a concurrent interview and record review, on October 29, 2021, at 11:25 a.m., conducted with CN 1, Patient 34's MAR indicated the following:

- Risperdal six mg, give two tablets po at night, due at 9 p.m.; and

- Depakote 500 mg, give one tablet po at night, due at 9 p.m.

There was no documented evidence the 9 p.m. dose for Risperdal was administered to Patient 34 on October 22, 24, 26, and 27, 2021

There was no documented evidence the 9 p.m. dose for Depakote was administered to Patient 34 on October 26 and 27, 2021.

CN 1 stated when medication was administered to the patient, the licensed nurse should initial on the time the medication was given to the patient.

CN 1 stated when the medication was not given to the patient as scheduled, the licensed nurse should document on the MAR by circling the time the medication was due and the RN should document the reason that the medication was not given.

CN 1 stated there was no documentation the medications were administered to Patient 25 on the dates and times mentioned above.

CN 1 stated there was no documentation as to why the medications were not administered as scheduled.

e1. During a concurrent interview and record review, on October 29, 2021, at 8:10 a.m., conducted with the DON, Patient 35's record was reviewed. The "History and Physical" indicated Patient 35 was admitted to the facility on October 12, 2021, for psychiatric treatment.

Patient 35's "Practitioner Order Sheet," dated October 22, 2021, indicated to administer the following medications:

- Neosporin (antibiotic ointment) apply to bilateral (both sides) soles of feet every 12 hours for five days; and

- Vaseline (ointment used for dry skin) apply to bilateral soles of feet once a day as needed.

Patient 35's MAR, dated October 23, 2021, indicated the physician's order was transcribed as "...Neosporin to bil (bilateral) soles of feet x 5D (five days) q12 (every 12 hours) PRN (as needed)."

The "Practitioner Order Sheet" indicated the licensed nurse noted the medication order on October 24, 2021 (two days after the medication order was written).

There was no documented evidence the physician's order for the medications mentioned above were transcribed in Patient 35's Medication Administration Record (MAR) on October 22, 2021.

The DON stated the physician's medication order on October 22, 2021, was not processed timely because the licensed nurse did not note the order until two days after it was written.

The DON stated Neosporin was not transcribed in Patient 35's MAR on October 22, 2021, so it was not administered to the patient.

The DON stated when the physician's order for Neosporin was transcribed in Patient 35's MAR on October 23, 2021, it was written incorrectly. The DON stated the Neosporin order was written in the MAR as PRN and the order was to be given every 12 hours for five days.

The DON stated the Neosporin should have been administered to Patient 35 on a routine schedule as ordered by the physician.

The DON stated it was a medication error for not administering the Neosporin to Patient 35 as ordered by the physician.

The DON stated when the licensed nurse noted a medication order, the order would be faxed to the pharmacy and the pharmacy should verify and transcribe the order in the patient's MAR.

e2. Patient 35's Medication Administration Record (MAR) indicated the following:

- Macrobid (antibiotic) 100 mg, give one capsule po every 12 hours for seven days, due at 9 a.m., and 9 p.m.;

- Zyprexa (antipsychotic medication) 15 mg, give two tablets po in the morning and at night, due at 9 a.m., and 9 p.m.;

- Inderal (medication used for anxiety) 10 mg, give one tablet po three times a day, due at 9 a.m., 1 p.m., and 5 p.m.; and

- Clonidine (medication used for high blood pressure could also be used for anxiety) 0.1 mg, give one tablet two times a day, due at 9 a.m., and 5 p.m.

There was no documented evidence the 9 a.m., dose for Macrobid was administered to Patient 35 on October 14, 2021.

There was no documented evidence the 9 p.m., dose for Macrobid was administered to Patient 35 on October 13 and 16, 2021.

There was no documented evidence the 9 p.m. dose for Zyprexa was administered to Patient 35 on October 21 and 22, 2021.

There was no documented evidence the 1 p.m., and 5 p.m., doses of Inderal were administered to Patient 35 on October 22, 2021.

There was no documented evidence the 5 p.m., dose for Clonidine was administered to Patient 35 on October 22 and 28, 2021.

The DON stated when a medication was administered to the patient, the licensed nurse should initial on the time the medication was given to the patient.

The DON stated when the medication was not given to the patient as scheduled, the licensed nurse should document on the MAR by circling the time the medication was due and the RN should document the reason that the medication was not given.

The DON stated there was no documentation the medications were administered to Patient 35 on the dates and times mentioned above.

The DON stated there was no documentation as to why the medications were not administered as scheduled.

During a review of the facility's policy and procedure (P&P) titled, "Medication Errors/Adverse Drug Events," reviewed in July 2020, the P&P indicated, "...Several types of medication errors exist which include...Omission Error: The failure to administer an ordered dose to a patient before the next scheduled dose, if any...Unauthorized Drug Error: Administration to the patient of medication not authorized by a legitimate prescriber for the patient..."

f. During a concurrent interview and record review, on November 1, 2021, at 10:10 a.m., with Charge Nurse (CN) 1, Patient 36's record was reviewed. The "History and Physical" indicated Patient 36 was admitted to the facility on October 21, 2021, for alcohol detoxification.

Patient 36's "Inpatient Admission Orders," dated October 21, 2021, indicated, "...CIWA Assessment...CIWA Assessments Protocol until Discontinued by MD (physician) Q2hrs (every two hours) x (for) 24Hrs; Then Q4hrs x 24Hrs; Then continue QShift...

Clonidine (medication used for high blood pressure [BP]) 0.1 mg PO Q12hrs (every 12 hours) PRN (as needed)...Elevated Blood Pressure...> (above) 160...> 100..."

Patient 36's physician's telephone order was received on October 21. 2021, at 4 p.m. The order indicated, "...Librium (medication used for alcohol withdrawal symptoms) 25 mg PO Q4hr PRN for CIWA > 8 x (for) 48 hours..."

The "Clinical Institute Withdrawal Assessment - Alcohol (CIWA -Ar) Score Sheet," indicated the following:

- On October 21, 2021, at 4 p.m., Patient 36 had a CIWA score of 19;

- On October 21, 2021, at 8 p.m., Patient 36 had a CIWA score of 14;

- On October 21, 2021, at 10 p.m., Patient 36 had a CIWA score of 16;

- On October 22, 2021, at 6 a.m., Patient 36 had a CIWA score of 14;

- On October 22, 2021, at 8 p.m., Patient 36 had a CIWA score of 13; and,

- On October 24, 2021, at 9 a.m., Patient 36 had a CIWA score of 9.

There was no documented evidence Librium was administered to Patient 36 on October 21, 22, and 24, 2021, when the patient's CIWA score was >8 as indicated in the physician's order.

Further review of the "Clinical Institute Withdrawal Assessment - Alcohol (CIWA -Ar) Score Sheet," indicated Patient 36 had the following BP readings:

- On October 21, 2021, at 4 p.m., the patient's BP was 174/78 millimeters of mercury (mmHg - unit of measurement for BP);

- On October 21, 2021, at 8 p.m., the patient's BP was 170/80 mmHg; and

- On October 23, 2021, at 9 p.m., the patient's BP was 176/82 mmHg.

There was no documented evidence Clonidine was administered to Patient 36 for elevated BP on October 21 and 23, 2021, as indicated in the physician's order.

CN 1 stated when a patient was admitted for alcohol detoxification, the CIWA protocol would be initiated.

CN 1 stated based on the patient's CIWA score the nurse would give PRN medication as ordered by the physician.

CN 1 stated Patient 36 should have been given Librium when the patient's CIWA score was > 8.

CN 1 stated the patient's vital signs (BP, pulse rate, and heart rate) should be checked when the patient was assessed for CIWA.

CN 1 stated Patient 36 should have been given Clonidine for high BP readings.

CN 1 stated CIWA was an important assessment tool for patients with alcohol withdrawal. CN 1 stated following the CIWA protocol would help in the patients' assessment to provide necessary interventions to help patients from experiencing alcohol withdrawal symptoms like hypertensive crisis (uncontrolled high blood pressure), seizure, tremors, and anxiety.

During a review of the facility's P&P titled, "Clinical Institute Withdrawal Assessment (CIWA) Procedure," reviewed in May 2020, the P&P indicated, "...All patients are assessed upon admission for substance abuse history. Patients admitted with a recent history of alcohol abuse will be assessed for withdrawal symptoms utilizing the CIWA..."

2a. During a concurrent interview and record review, on October 30, 2021, at 10:50 a.m., conducted with Registered Nurse (RN) 2, Patient 5's record was reviewed. Patient 5 was admitted to the facility on October 21, 2021, with a diagnosis of schizophrenia.

Patient 5's MAR indicated Ativan 2 mg by mouth was administered PRN for anxiety/agitation on the following dates and times:

- October 23, 2021, at 11:30 p.m.;

- October 25, 2021, at 9 p.m.;

- October 26, 2021, at 11 a.m.;

- October 27, 2021, at 10 p.m.; and,

- October 28, 2021, at 8 p.m.

There was no documented evidence indicating a reassessment of Patient 5's anxiety/agitation was done after Ativan was administered for the above administration dates and times.

RN 2 stated an assessment for all PRN medications should be done after being administered to determine whether the medication was effective.

b. During a concurrent interview and record review, on November 2, 2021, at 2:05 p.m., conducted with CN 1, Patient 6's record was reviewed. Patient 6 was admitted to the facility on October 15, 2021, with a diagnosis of depression (a mood disorder).

Patient 6's MAR indicated Ativan 2 mg by mouth was administered PRN for agitation on the following dates and times:

- October 23, 2021, at 10 p.m.;

- October 26, 2021, at 8 p.m.;

- October 30, 2021, at 9 p.m.; and,

- November 1, 2021, at 8 p.m.

Patient 6's MAR also indicated Benadryl (a medication used to treat allergy symptoms, motion sickness, and sleep difficulties) 50 mg by mouth was administered PRN for anxiety (a mood disorder) on the following dates and times:

- October 23, 2021, at 8:54 a.m., and at 9 p.m.;

- October 26, 2021, at 8 p.m.;

- October 29, 2021, at 1:05 p.m., and at 9 p.m.;

- October 30, 2021, at 9 p.m.; and,

- November 1, 2021, at 8 p.m.

CN 1 reviewed Patient 6's record and stated there was no documentation indicating a reassessment of Patient 6's agitation and/or anxiety was done after the administration of the above PRN medications.

CN 1 stated an assessment for all PRN medications should be done after being administered to determine whether the medication was effective.

c. During a concurrent interview and record review, on November 2, 2021, at 4:45 p.m., conducted with CN 1, Patient 7's record was reviewed. Patient 7 was admitted to the facility on October 19, 2021, with a diagnosis of schizophrenia.

Patient 7's MAR indicated Benadryl 0 mg by mouth was administered PRN for anxiety on the following dates and times:

- October 26, 2021, at 9 p.m.;

- October 28, 2021, at 10 p.m.;

- October 29, 2021, at 10 p.m.;

- October 30, 2021, at 9 p.m.;

- October 31, 2021, at 01:59 a.m.; and,

- November 1, 2021, at 9 p.m.

CN 1 reviewed Patient 7's record and stated there was no documentation indicating a reassessment of Patient 7's anxiety was done after the administration of above PRN medications.

CN 1 stated an assessment for all PRN medications should be done after being administered to determine whether the medication was effective.

d. During a concurrent interview and record review, on October 29, 2021, at 4:10 p.m., conducted with CN 1, Patient 34's record was reviewed. The "History and Physical" indicated Patient 34 was admitted to the facility on October 17, 2021, for psychiatric treatment.

Patient 34's "Medication Administration Record (MAR)" indicated the following physician's orders:

- Haldol (an antipsychotic medication) five mg PO, give one tablet every six hours PRN for severe agitation and anxiety;

- Ativan two mg PO, give one tablet every six hours PRN for severe agitation and anxiety;

- Benadryl 50 mg PO, give one capsule every six hours PRN for severe agitation and anxiety;

- Milk of Magnesia (for constipation) 30 mililiters (ml) PO, give daily PRN.

The MAR indicated Patient 34 was administered Haldol on October 17, 2021, at 8:40 p.m., October 19, 2021, at 6 p.m., and October 22, 2021, at 4:20 p.m.

The MAR indicated Patient 34 was administered Ativan on October 17, 2021, at 8:40 p.m., October 19, 2021, at 6 p.m., October 21, 2021, at 9 p.m., and October 22, 2021, at 4:20 p.m.

The MAR indicated Patient 34 was administered Benadryl on October 17, 2021, at 8:40 p.m., October 19, 2021, at 2:10 a.m. and 6 p.m., October 21, 2021, at 9 p.m., and October 22, 2021, at 4:20 p.m.

The MAR indicated Patient 34 was administered Milk of Magnesia on October 25, 2021, at 2:15 a.m.

There was no documented evidence Patient 34's behavior was reassessed after the administration of Haldol, Ativan, and Benadryl.

There was no documented evidence Patient 34 was reassessed for the effectiveness of the PRN medication.

CN 1 stated when the patient was given PRN medication, the nurse should reassess the patient to know if the medication given was effective or if further intervention was needed.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration and Records," reviewed in July 2020, the P&P indicated, "...Documentation of a patient's response to PRN medications must be documented..."

3a. A review of Patient 11's record was conducted. Patient 11 was admitted to the facility on October 14, 2021, with a diagnosis of schizophrenia.

A review of Patient 11's physician orders and a concurrent interview and record review, was conducted with CN 1 on November 2, 2021, at 2:50 p.m. The record failed to show that a 24 hour chart check was conducted on October 16 and 17, 2021.

CN 1 stated the 24 hour chart check should be done on the night shift and was missed on those two dates. CN 1 further stated that omission could lead to medications and other physician orders to not be transcribed properly onto the medication administration record (MAR).

b. On November 1, 2021, a review of Patient 13's record was conducted. Patient 13 was admitted to the facility on October 19, 2021, with a diagnosis of schizophrenia.

A review of Patient 13's physician orders and a concurrent interview and record review was conducted with CN 1 on November 2, 2021, at 3 p.m. The record failed to show a 24 hour chart check was conducted on October 21, 26, 28, 29, 30 and 31, 2021. CN 1 stated the 24 hour chart check should be done on the night shift and was missed on multiple days.

A review of the facility policy and procedure titled, "Medication Management (Annual Review: 7/2020)" was conducted. The procedure indicates, "The computer generated Medication Administration Record (MAR) will be utilized as follows: Prior to using the MAR, a twenty-four hour check of licensed practitioner's orders compared against the computerized MAR will be performed. This will be done nightly by nursing to assure accuracy of transcription and accurate computer entry by the Pharmacy Department. Any discrepancies must be correct on the MAR, and the Pharmacy must be notified of any discrepancies on the MAR... If correct, the night nurse must sign as verification/reconciliation on the MAR and indicated the twenty-four hour check has been completed by signing and dating the licensed practitioner order form."

4. On November 1, 2021, a review of Patient 13's record was conducted. Patient 13 was admitted to the facility on October 19, 2021, with a diagnosis of schizophrenia.

A review of the MAR was conducted. The MAR reflected Zyprexa (to treat schizophrenia) 10 milligrams intramuscularly (IM) was ordered on October 29, 2021, to be administered if Patient 13 refused to take the oral version of the medication.

The documentation on the MAR indicated Zyprexa was administered to Patient 13 IM on October 30, 2021, at 9 a.m., and at 5 p.m. The documentation failed to show the location where the IM was administered.

A review of the facility policy and procedure titled, "Medication Administration and Records (Annual Review: 7/2020)" was conducted. The procedure indicated, "...IM injection sites should be recorded by the nurse with the location of the injection site..."

5. On November 1, 2021, a review of Patient 13's record was conducted. Patient 13 was admitted to the facility on October 19, 2021, with a diagnosis of schizophrenia.

A review of the physician orders and an concurrent interview and record review was conducted with CN 1 on November 2, 2021, at 4:30 p.m. An order for "Invega Sustenna 234 mg IM x 1 indication psychosis" (long acting treatment for schizophrenia) was reviewed. The order failed to include the date and time the medication was ordered.

CN 1 stated when a medication was ordered, the date and time the medication was ordered has to be documented.

A review of the facility policy and procedure titled, "Medication Administration and Records (Annual Review: 7/2020)" was conducted. The policy indicated, "...Medication orders at a minimum must include the following elements: legible name, military time preferred, date..."

6. During a concurrent interview and record review, on October 30, 2021, at 10:35 a.m., conducted with RN 4, Patient 3's record was reviewed. Patient 3 was admitted to the facility on October 28, 2021, with a diagnosis of schizophrenia.

The physician's telephone orders, dated October 28, 2021, at 2:30 a.m., indicated to administer Haldol 10 mg by mouth every night at bedtime for agitation/psychosis (a mental illness) and Depakote 1000 mg by mouth every night at bedtime for mood.

The nurse's notes, dated October 28, 2021, at 2:41 a.m., indicated, "...(Patient 3) was signing safety contract (admission document) before abruptly stabbing staff member's head (with) pen. Incident was unprovoked and spontaneous...was provided with medication per MD medication orders..."

There was no documentation on Patient 3's MAR, dated October 28, 2021, that indicated any medication was administered.

RN 4 stated the medication dispensing system indicated Haldol and Depakote were removed on October 28, 2021, for Patient 3, but there was no documentation on the MAR indicating these medications were administered.

RN 4 stated all medications should be initialed by the administering nurse on the MAR when the medications are given.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration and Records," reviewed in July 2020, the P&P indicated, "...To indicate the administration of a scheduled medication, the nurse will cross out the time the medication was administered and initial directly to the right of the medication with time..."

7a. During a concurrent observation and interview, on October 29, 2021, at 9:45 a.m., conducted with Licensed Vocational Nurse (LVN) 2, in the Magnolia unit medication room, LVN 2 was observed during medication pass. Multiple plastic cups with patient labels and unopened medications were observed.

LVN 2 stated he prepared the entire unit's medications for the scheduled morning doses. LVN 2 stated he initialed each patient's MAR after preparing each medication and prior to administering. LVN 2 further stated he did not prepare or administer medications to each patient one at a time.

b. An observation of the medication pass was conducted on October 29, 2021, from 9 a.m. to 9:30 a.m. LVN 1 was noted preparing to dispense medications from the medication room. A group of approximately 20 medication cups were observed in the medication room, each containing medications which were still in their individual bubble packs.

A concurrent interview was conducted with LVN 1 who stated she pulled all the patient's medications that she planned to dispense for the 9 a.m. medication pass and did not pull each patient's medication one at a time. LVN 1 further stated she placed her initials on the MAR next to each medication she planned to administer to the patient prior to administering the medication.

An interview was conducted with RN 4 on October 29, 2021, at 11 a.m. RN 4 stated medications were to be pulled individually, patient by patient. RN 4 further stated the MAR should not be signed prior to administering a medication because the licensed nurse may not know if it was actually administered or not. RN 4 stated the MAR should be signed when the medication was administered.

A review of the facility policy and procedure titled, "Medication Administration and Records (Annual Review: 7/2020)" was conducted. The policy indicated, "...The nurse will prepare and administer only one patient's medications at a time...To indicate the administration of a scheduled medication, the nurse will cross out the time the medication was administered and initial directly to the right of the medication with time..."

8a. During an observation on October 29, 2021, at 9:45 a.m., in the Magnolia unit medication room, LVN 2 was observed du

Based on observation, interview, and record review, the facility failed to ensure a physician's order was obtained and education regarding the medication was provided to the patient prior to the patient self administering her Flonase, for one patient (Patient 11). These failures may result in ineffective administration of the medication and a lack of understanding of the medication's purpose.

Findings:

An observation of the medication pass was conducted on October 29, 2021, at 9 a.m. Licensed Vocational Nurse (LVN) 1 was observed handing a Flonase Inhaler to Patient 11. Patient 11 took the inhaler from LVN 1 and administered the medication to herself and handed the inhaler back to LVN 1.

On October 30, 2021, a review of Patient 11's record was conducted. Patient 11 was admitted to the facility on October 14, 2021, with a diagnosis of schizophrenia (a mental health disorder involving a breakdown in the relation between thought, emotion, and behavior leading to withdrawal from reality).

Further review of Patient 11's record reflected a physician's order to administer Flonase, one spray in each nostril daily for nasal congestion. However, the record failed to show a physician's order indicating Patient 11 could self administer the medication. The record also failed to show education was provided to Patient 11 regarding how to administer the medication.

An interview was conducted with the Director of Nursing (DON), and Charge Nurse (CN) 1, on November 2, 2021, at 4 p.m. The DON stated a physician's order was required in order for a patient to self administer a medication. CN 1 stated a patient should be educated on how to administer the inhaler prior to self administering it.

A review of the facility policy and procedure titled, "Medication Administration and Records (Annual Review: 7/2020)" was conducted. The policy indicated, "...Self administration of medication is not allowed in this facility, with the exception of inhalers, vaginal and rectal administrations. This is due to the nature of the facility and safety concerns. The nurse will be responsible for determining the competency of the patient to self administer the above mentioned medications. A patient handout or instructions for use by the nurse will be provided to the patient and a notation of competency will be noted in the patient's record..."

Based on interview and record review, the facility failed to ensure:

1. The patients' medical records were accurately written, for two patients (Patients 32 and 35) (A 438);

2. The Medication Administration Record (MAR) accurately reflected the time the medication was administered to the patients (A 438);

3. There were legible printed names and signatures for staff members providing care and administering medications for eight sampled patients (Patients 6, 7, 32, 33, 34, 35, 39, 40) (A 450);

4. Full informed consent was obtained for patients or their guardians, particularly those who were administered psychotropic (drug affecting how the brain works) medications, for five patients (Patients 23, 25, 27, 29, and 32) (A 466).

5. The informed consent right for a Spanish speaking patient and the opportunity to understand and consent to care was provided in their language as guaranteed, for one patient (Patient 27) (A 466); and

6. The physician orders for tests, medications, and required observations of patients experiencing chemical detoxification and alcohol withdrawal were complete and authenticated, for six patients (Patients 17, 21, 23, 24, 26, and 32) (A 467).

The cumulative effects of these systemic problems resulted in the hospital's inability to provide Medical Record Services in an effective manner and with respect to patient's rights.

Based on interview and record review, the facility failed to ensure:

1. For two sampled patients (Patients 32 and 35), the patients' medical records were accurately written; and,

2. The Medication Administration Record (MAR) accurately reflected the time the medication was administered to the patients.

These failures had the potential for the contents of these patient's medical records, which included information of care and treatment provided to the patients, to be invalid and inaccurate.

Findings:

1a. During a concurrent interview and record review, on October 30, 2021, at 10:15 a.m., with Licensed Vocational Nurse (LVN) 4, Patient 32's record was reviewed. The "History and Physical," indicated Patient 32 was admitted to the facility on October 28, 2021, for psychiatric treatment and alcohol detoxification (the process of clearing the body of drugs or alcohol consumed by an individual).

The "Inpatient Admission Orders," dated October 28, 2021, indicated, "...CIWA Assessment...CIWA Assessments Protocol until Discontinued by MD (physician) Q2hrs (every two hours) x (for) 24Hrs; Then Q4hrs x 24Hrs; Then continue QShift..."

The "Clinical Institute Withdrawal Assessment - Alcohol (CIWA -Ar) Score Sheet," indicated the following on October 28, 2021:

- At 1:25 p.m., Patient 32's CIWA was initiated.

Patient 32's vital signs (VS - blood pressure, pulse rate, and respiratory rate) were taken and the patient's CIWA was 11;

- There was no documented evidence Patient 32's VS were taken or the CIWA was conducted at 3 p.m., and 5 p.m.

Columns under the 3 p.m., and 5 p.m., were blank;

- At 7 p.m., and 9 p.m., Patient 32's VS were taken and the patient's CIWA was 7; and,

- At 11 p.m., Patient 32's VS were taken and the patient's CIWA was 10.

The "Clinical Institute Withdrawal Assessment - Alcohol (CIWA -Ar) Score Sheet," indicated the following on October 29, 2021:

- At 1 a.m., and 3 a.m., Patient 32 was asleep;

- At 5:49 a.m., Patient 32's VS were taken and the patient's CIWA was 10; and,

- There was no documented evidence Patient 32's VS were taken or the CIWA scoring was conducted at 7 a.m., 9 a.m., 11 a.m., 1 p.m., and 5 p.m.,

Columns under the time of 7 a.m., 9 a.m., 11 a.m., 1 p.m., and 5 p.m., were blank.

LVN 4 stated when a patient was admitted for alcohol detoxification, the CIWA protocol would be initiated.

LVN 4 stated the assigned medication nurse on the unit would be responsible for conducting the patient's CIWA per protocol.

LVN 4 stated there was no documentation Patient 32's CIWA was conducted on October 28, 2021, at 3 p.m., and 5 p.m.

LVN 4 stated there was no documentation Patient 32's CIWA was conducted on October 29, 2021, at 7 a.m., 9 a.m., 11 a.m., 1 p.m., and 5 p.m.

A copy of the CIWA score sheet was requested and provided by LVN 4 on October 30, 2021, at 10:25 a.m.

During a record review on November 1, 2021, at 4 p.m., conducted with Charge Nurse (CN) 1, Patient 32's "Clinical Institute Withdrawal Assessment - Alcohol (CIWA -Ar) Score Sheet," was reviewed.

The CIWA score sheets with missing CIWA assessments identified with LVN 4 during the record review on October 30, 2021, was now filled with Patient 32's CIWA assessments and score. Each of the missing columns from a previous record review was now filled, completed, and a nurse's initial was written at the bottom of each column (where the columns were blank and no initials were written from the previous record review)."

In a concurrent interview with CN 1, CN 1 stated there was no documentation the new entry on the CIWA score sheet indicated a "late entry."

CN 1 stated, "that's not good, there was obvious falsification."

CN 1 stated with the CIWA score sheet (reviewed on November 1, 2021, which was initially reviewed on October 30, 2021), there was now a question of the validity of Patient 32's record, "if it was even accurate."

During an interview on November 1, 2021, with the Director of Nursing (DON), the DON stated she was aware some of the patients' CIWA assessments were not completed when LVN 4 reported to her that issue on October 30, 2021, after the deficiency was identified during the record review.

The DON reviewed the copy of CIWA score sheet received on October 30, 2021, and the current copy on Patient 32's record. The DON stated there was falsification of the current copy since the missing CIWA assessments for Patient 32 was now filled and completed.

The DON stated she would have to investigate and check the initials of the licensed nurses written on each of the missing columns that were now completed and filled in.

In a follow up interview with the DON at 4:15 p.m., the DON stated the nurse's initial on the "falsified copy" (copy of record reviewed on November 1, 2021, which was initially reviewed on October 30,2021) of the CIWA score sheet for October 28, 2021, at 3 p.m., and 5 p.m., was LVN 6.

The DON stated LVN 6 was on the schedule and worked on October 28, 2021.

The DON stated LVN 6 was not on the schedule and did not come to work from October 29 to November 1, 2021.

The DON stated the nurse's initial on the "falsified copy" (copy of record reviewed on November 1, 2021, which was initially reviewed on October 30,2021) of the CIWA score sheet for October 29, 2021, at 7 a.m., 9 a.m., 11 a.m., 1 p.m., and 5 p.m. was not legible. The DON stated there was no corresponding signature for the initials written on the CIWA score sheet to identify the nurse.

During an interview on November 2, 2021, at 4:12 p.m., with CN 1, CN 1 stated the nurse's initial on the "falsified copy" (copy of record reviewed on November 1, 2021, which was initially reviewed on October 30,2021) of the CIWA score sheet for October 29, 2021, at 7 a.m., 9 a.m., 11 a.m., 1 p.m., and 5 p.m. was not legible. CN 1 stated there was no corresponding signature for the initials written on the CIWA score sheet to identify the nurse.

CN 1 stated the staffing schedule on October 29, 2021, dayshift (7 a.m., to 7 p.m.) indicated the medication nurse assigned to Patient 35's unit was LVN 7.

CN 1 compared LVN 7's initial from the "falsified copy" (copy of record reviewed on November 1, 2021, which was initially reviewed on October 30,2021) of the CIWA score sheet for October 29, 2021. CN 1 stated after comparing LVN 7's initials to the initials on the "falsified copy,"(copy of record reviewed on November 1, 2021, which was initially reviewed on October 30,2021) it was not the initial of LVN 7.

b. During a concurrent interview and record review, on October 29, 2021, at 12:20 p.m., with Charge Nurse (CN) 1, Patient 35's record was reviewed. The "History and Physical" indicated Patient 35 was admitted to the facility on October 12, 2021, for psychiatric treatment.

Patient 35's "Interdisciplinary Treatment Plan Master Sheet (ITPMS)," indicated the initial treatment plan was conducted on October 15, 2021.

There was no documented evidence an Interdisciplinary Treatment Plan update was conducted for Patient 35 seven days after the ITPMS was completed on October 15, 2021 (a total of 14 days).

CN 1 stated after the initial treatment plan was conducted, a treatment plan update should be conducted by the interdisciplinary team (a group of healthcare providers from different fields who work together to manage the needs of the patient) every seven days.

During a record review on November 1, 2021, at 6:05 p.m., conducted with CN 1, Patient 35's record was reviewed. A completed "Interdisciplinary Treatment Plan Update (ITPU)," was found in the patient's record.

Patient 35's ITPU was signed by the following staff:

- Social Worker (SW) 1 on October 21, 2021;

- The Activity Therapist on October 22, 2021; and,

- Registered Nurse (RN) 1 on October 21, 2021.

In a concurrent interview with CN 1, CN 1 stated there was no documentation the ITPU was conducted for Patient 35 when the patient's record was reviewed on October 29, 2021.

CN 1 checked the staffing schedule on October 21, 2021. CN 1 stated RN 1 was not on schedule and did not work on October 21, 2021.

During an interview on November 2, 2021, at 11:45 a.m., with SW 1, SW 1 stated for the patient's treatment plan, she usually would meet with the physician and RN first, then would meet next with the rest of the team.

SW 1 stated after the treatment plan was completed and updated, she would review the plan with the patient.

SW 1 stated she does not hold on to the ITPMS or ITPU packet, if she needed to take it out from the patient's record, she would put it back right away or the next day.

SW 1 stated she does not hold on to any documents of the patient for more than 24 hours. SW 1 stated she returns the document immediately to the patient's record.

During a review of the facility's policy and procedure (P&P) titled, "Documentation Protocol," reviewed in March 2021, the P&P indicated, "...All patient medical record entries are to be:
- legible,
- complete,
- dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, and
- Consistent with facility policies and procedure...

Authentication
- Medical record entries are to be authenticated by the author of the entry.
- Entries are to be confirmed by written signature, credentials, date and time.
- Staff authorized to sign a medical record entry shall NOT authorized or instruct Anyone to sign his/her name in any type of document, paper or electronic, when that document is part of the patient's medical record...

Omission/Late Entry...
- Identify the new entry as a "late entry"
- Sign, Date and Time the additional information by using the date/time you are adding the information, NOT when the observation or activity previously occurred and should have been entered. Assessments and observations (anything you cannot recall as a fact) are not to be documented after the end of your shift...

DO NOT...
- Engage in back dating any document in a medical record;
- Record any inaccurate, false, or misleading information in a medical record;
- Sign another person's name on a document in a medical record..."



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2. On November 3, 2021, at 8:45 a.m., during an interview conducted with Licensed Vocational Nurse (LVN) 30, LVN 30 stated 18 patients were given their morning medications. LVN 30 stated the documentation of administration and/or refusal of medications would be completed after all the medications were administered to the 18 patients.

On November 3, 2021, at 9:45 a.m., during an interview conducted with LVN 31, LVN 31 stated the medication administration should be documented on the MAR after completion of administration for each of the patient.

On November 4, 2021, at 10 a.m., during an interview conducted with LVN 32, LVN 32 stated medication administration should be documented on the MAR one patient at a time.

A review of the hospital policy and procedure titled, "The Role of Nursing in Medication Administration" last revised, "1/2020" indicated:

"...Time of administration & record-keeping: nursing will record the exact time of each medication administered. Recording the time in this way will allow auditors of the Medication Administration Records to determine if the nursing staff has complied with policy..."

Based on interview and record review, the facility failed to ensure there were legible printed names and signatures for staff members providing care and administering medications for eight sampled patients (Patients 6, 7, 32, 33, 34, 35, 39, 40).

These failures may impact the quality and safety of patient care.

1a. During a concurrent interview and record review, on November 2, 2021, at 2:25 p.m., conducted with Charge Nurse (CN) 1, Patient 6's record was reviewed. Patient 6 was admitted to the facility on October 15, 2021, with a diagnosis of depression (mood disorder that causes a persistent feeling of sadness and loss of interest).

Patient 6's medication administration record (MAR) for scheduled and PRN (as needed) medications, dated October 24, 2021, through November 1, 2021, were reviewed.

The MAR reflected written staff initials next to the times each medication was administered during the above date range.

CN 1 stated there were no legible printed names or signatures of nursing staff on the bottom of each page of Patient 6's MAR to coincide with each staff member's initials.

CN 1 stated every page of the MAR should have the legible printed names and signatures of every nursing staff member that has initialed the MAR.

b. During a concurrent interview and record review, on November 2, 2021, at 4:45 p.m., with Charge Nurse (CN) 1, Patient 7's record was reviewed. Patient 7 was admitted to the facility on October 19, 2021, with a diagnosis of schizophrenia (serious mental health disorder in which people interpret reality abnormally).

Patient 7's medication administration record (MAR) for scheduled and PRN (as needed) medications, dated October 26, 2021, through November 1, 2021, were reviewed.

The MAR reflected written staff initials next to the times each medication was administered during the above date range.

CN 1 stated there were no legible printed names or signatures of nursing staff on the bottom of each page of Patient 7's MAR to coincide with each staff member's initials.

CN 1 stated every page of the MAR should have the legible printed names and signatures of every nursing staff member that has initialed the MAR.


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c. During a concurrent interview and record review, on November 2, 2021, at 4:12 p.m., with Charge Nurse (CN) 1, Patient 32's record was reviewed. The "History and Physical," indicated Patient 32 was admitted to the facility on October 28, 2021, for psychiatric treatment and alcohol detoxification (a process of clearing the body of drugs and alcohol consumed by an individual).

Patient 32's "Medication Administration Record (MAR)", dated October 28 to 30, 2021, contained three written staff initials next to each medication administered to the patient. The signature space at the bottom of the MAR contained two signatures of the licensed nurses.

CN 1 stated one of the signatures was not legible and he was unable to identify who the licensed staff was who administered medications to Patient 32.

CN 1 stated one of the licensed nurses did not sign the signature page that would identify who administered the medications to Patient 32.

d. During a concurrent interview and record review, on November 2, 2021, at 4:10 p.m., conducted with Charge Nurse (CN) 1, Patient 33's record was reviewed. The "Initial Psychiatric Evaluation" indicated Patient 33 was admitted to the facility on October 12, 2021, for a 5150 (involuntarily detained for a 72-hour psychiatric hospitalization) due to grave disability.

Patient 33's "Medication Administration Record (MAR)," dated October 23 to 26, 2021, contained six written staff initials next to the time for each medication administered to the patient. The signature space at the bottom of the MAR contained one signature of the licensed nurse.

CN 1 stated he could not identify who were the other licensed nurses who administered medications to Patient 33 because there was no signature written on the patient's MAR.

CN 1 stated when a licensed nurse administered a medication to the patient, the licensed nurse should write their legible signature next to their initials in the MAR for identification.

e. During a concurrent interview and record review, on November 2, 2021, at 4:05 p.m., with Charge Nurse (CN) 1, Patient 34's record was reviewed. The "History and Physical" indicated Patient 34 was admitted to the facility on October 17, 2021, for psychiatric treatment.

Patient 34's "Medication Administration Record (MAR)," dated October 19, 20, 22, 25, and 28, 2021, contained staff initials next to the time for each medication administered to the patient. The signature space at the bottom of the MAR did not have signatures of the licensed nurses to correspond to the written initials indicating medication was administered to the patient.

Patient 34's MAR dated October 23, 2021, contained a staff initial next to the medication administered to the patient. The signature space at the bottom of the MAR contained a signature of the licensed nurse.

CN 1 stated the signature was not legible and he was unable to identify the licensed staff who administered the medication to Patient 32.

CN 1 stated he could not identify who the other licensed nurses who administered medications to Patient 33 since there was no signature written in the patient's MAR.

CN 1 stated when a licensed nurse administered a medication to the patient, the licensed nurse should write their signatures legibly next to their initials in the MAR for identification.

f. During a concurrent interview and record review, on November 2, 2021, at 4:08 p.m., with Charge Nurse (CN) 1, Patient 35's record was reviewed. The "History and Physical" indicated Patient 35 was admitted to the facility on October 12, 2021, for psychiatric treatment.

Patient 35's "Medication Administration Record (MAR)," dated October 13 to 15, 2021, contained four written staff initials next to each medication administered to the patient. The signature space at the bottom of the MAR contained two signatures of the licensed nurses.

Patient 35's MAR dated October 16 and 17, 2021, contained three written staff initials next to each medication administered to the patient. The signature space at the bottom of the MAR contained two signatures of the licensed nurses.

Patient 35's MAR dated October 21, 22, 27, and 28, 2021, contained staff initials next to the time for each medication administered to the patient. The signature space at the bottom of the MAR did not have signatures of the licensed nurses to correspond with the written initials indicating medication was administered to the patient.

CN 1 stated one of the signatures was not legible and was unable to identify the licensed staff who administered medication to Patient 35 from October 13 to 15, 2021.

CN 1 stated one of the signatures was not legible and unable to identify the licensed staff who administered medication to Patient 35 on October 16 and 17, 2021.

CN 1 stated he could not identify the other licensed nurses who administered medications to Patient 35, because there were no signatures written in the patient's MAR to correspond with the written initials indicating medication was administered to the patient from October 13 to 28, 2021.

CN 1 stated when a licensed nurse administered a medication to the patient, the licensed nurse should write their signature legibly next to their initials in the MAR for identification.

g. During a concurrent interview and record review, on November 2, 2021, at 4:19 p.m., with Charge Nurse (CN) 1, Patient 39's record was reviewed. The "History and Physical" indicated Patient 36 was admitted to the facility on October 28, 2021, for psychiatric treatment.

Patient 39's "Medication Administration Record (MAR)," dated October 30, 2021, contained staff initials next to the time for each medication administered to the patient. The signature space at the bottom of the MAR did not have signatures of the licensed nurses to correspond with the written initials indicating medication was administered to the patient.

CN 1 stated he could not identify the other licensed nurses who administered medications to Patient 39 because there were no signatures written in the patient's MAR to correspond with the written initials indicating medication was administered to the patient on October 30, 2021.

CN 1 stated when a licensed nurse administered a medication to the patient, the licensed nurse should write their signature legibly next to their initials in the MAR for identification.

h. During a concurrent interview and record review, on November 2, 2021, at 4:03 p.m., with Charge Nurse (CN) 1, Patient 40's record was reviewed. The "History and Physical" indicated Patient 40 was admitted to the facility on October 25, 2021, for psychiatric treatment.

Patient 40's "Medication Administration Record (MAR)," dated October 26 and 27, 2021, contained three written staff initials next to each medication administered to the patient. The signature space at the bottom of the MAR contained two signatures of the licensed nurses.

Patient 40's MAR dated October 28 and 29, 2021, contained three written staff initials next to each medication administered to the patient. The signature space at the bottom of the MAR contained one signature of the licensed nurse.

Patient 40's MAR dated October 30, 2021, contained staff initials next to the time for each medication administered to the patient. The signature space at the bottom of the MAR did not have signature of the licensed nurses to correspond to the written initials indicating medication was administered to the patient.

CN 1 stated one of the signature was not legible and was unable to identify the licensed staff who administered medication to Patient 40 on October 26 and 27, 2021.

CN 1 stated he could not identify the other licensed nurses who administered medications to Patient 40 since there were no signatures written in the patient's MAR to correspond with the written initials indicating medication was administered to the patient from October 26 to 30, 2021.

CN 1 stated when a licensed nurse administered a medication to the patient, the licensed nurse should write their signatures legibly next to their initials in the MAR for identification.

CN 1 stated it was important to have a legible signature on the patient's record for each licensed nurses providing care for patient safety. CN 1 stated the legible signature was a way to identify appropriate staff were providing care to the patient.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration and Records," reviewed in July 2020, the P&P indicated, "...All nurses administering medications must sign and initial the designated area at the bottom of the patient's MAR to allow for easy identification of the nurse who administered the medication..."

Based on interview, observation and record review, the facility failed to ensure full informed consent was obtained for patients or their guardians, particularly those who were administered psychotropic (drug affecting how the brain works) medications (Patients 23, 25, 27, 29, and 32). The facility failed to ensure the informed consent right was provided for a Spanish speaking Patient 27, and provided no opportunity to the patient or guardian to understand and consent to care in their language as guaranteed.

This failure violated the patient right of informed consent to have their care explained in full and legally consented for treatment from the point of inpatient admission to the facility and throughout their inpatient stay until discharge.

FINDINGS:

During a concurrent interview and review on November 3,2021 at 10:00 a.m., The Health Information Management Director (HIMD) provided the facility policy and procedures for informed consent which was reviewed. A policy titled, "Informed Consent for Psychotropic Medications," from the facility's policies under "Right and Individual Responsibilities" was provided on 11/3/21.

The policy "Informed Consent for Psychotropic Medication," included in its' last revision by the facility on 08/2019, that "No medication(s) as defined in this policy will be administered in the absence of a signed consent form".

During a review of records from July 2021 - October 2021:
· Patient 23's "Medication Consent - Psychotropics," was unsigned for July 22, 2021. The consent was for an antipsychotic drug Zyprexa (medication used to treat schizophrenia and bipolar disorders) and the consent did not have Ativan (medication used to treat anxiety) marked on the form to be administered. The record included a physician telephone order by the attending MD G to be administered from Day 1 to Day 5 of the inpatient stay.
· Patient 25's Conditions of Admission consents for July 14, 2021, were unsigned. No Medication Consent - Psychotropics was located in the medical record.
· Patient 27, admitted October 6, 2021, and discharged on October 25, 2021, had no informed consent on the Voluntary Admission consent and the Conditions of Admission. At discharge, the Medicare Message on Hospital Discharge and appeal rights for 10/25/21, was signed by two (2) facility RN's and not translated in Spanish, while it is noted in the Discharge Planning Summary notes "Pt speak Spanish only". No Medication Consent - Psychotropics was located in the medical record.
· Patient 29 was admitted on July 19, 2021, with a diagnosis of schizophrenia. The "Consent for Assessment/Medical Screening" was not signed. The "Coordination of Benefits" form was not signed and the Conditions of Admission were not signed. No Medication Consent - Psychotropics was located in the medical record.
· Patient 32 admitted on October 28, 2021, did not authorize or sign Authorization to Disclose Healthcare, Conditions of Admission, Financial Responsibility Acknowledgement, Participant Phone Agreement, and the documents witnessed by a sole facility LVN who noted "Refusal to sign...". There was an unwitnessed document titled "Request for Voluntary Admission and Authorization for Treatment," on 10/30/21, at the time of discharge. No Medication Consent - Psychotropics was located in the medical record, while the psychotropic medication Ativan was administered as noted in the Medication Administration record.

During an interview on 11/4/21, at 10:00 a.m., the Director of Nursing (DON) was asked how patients who spoke foreign languages were accommodated to obtain their consent to treatment, specifically Spanish speakers. The DON stated that there were two laptops located in the Medication Rooms that were accessible to facility staff that provided translation service by an audio and video link through a contracted language service company.

During an observation tour of the facility on 11/4/21 at 11:20 a.m., and at the clinical unit for chemical detoxification patients, the language translation laptop was requested from a nurse at the unit office. The laptop could not be located and was thought to be in the DON office, where it was later located. The DON demonstrated the use of the translation service at 11:50 a.m.

During an interview on 11/4/21 at 11:53 a.m., the Director of Clinical Service (DCS) was asked how Spanish translation on consents to treatment were handled. The DCS stated that there was a Spanish speaking social worker on duty from Monday - Friday at 8 a.m. to 4:30 p.m. If the social worker were not available, the language translation laptop would be utilized. A non-Spanish speaking Licensed Clinical Social Worker (LCSW) in the office was requested to locate the translation laptop and demonstrate its usage. The laptop could not be located at first and was eventually located at 12:24 p.m.,with searching assistance in the Admission Office. The LCSW was able to demonstrate how to link to the translation service after a significant delay. The LCSW was asked if training in the use of the translation laptop was provided at training orientation and the LCSW stated it was not.

Based on interview and record review, the facility failed to ensure complete and authenticated physician orders for tests, medications, and required observations of patients experiencing chemical detoxification and alcohol withdrawal, for six patients (Patients 17, 21, 23, 24, 26, and 32).

This failure had the potential for the staff involved in the care not to have the necessary information to monitor the patient's condition which could affect the care and treatment for Patients 17, 21, 23, 24, 26, and 32.

FINDINGS:

During an interview on November 3, 2021, at 8:40 a.m., the Health Information Management Director (HIMD) and the Health Information Management Corporate (HIMC) stated that telephone orders could be received and documented in the medical record from physicians, to be signed within 48 hours of receipt. The HIMD stated that no verbal orders were accepted from physicians according to the facility policy for Inpatient Patient Orders.

During a review of records of inpatients discharged from July 2021 - October 2021:
· Patient 17 was admitted to the facility on July 13, 2021, with a diagnosis of Alcohol Dependence. The Inpatient Admission Orders document was unsigned by attending physician MD C, for July 13, 2021, as well as the "CIWA Detox Orders" (Clinical Institute Withdrawal Assessment Detoxification) for medications ordered including Ativan (psychotropic medication used to treat anxiety).
· Patient 21 was admitted to the facility on October 21, 2021, with a diagnosis of Alcohol Dependence with Withdrawal. The Inpatient Admission Orders document was unsigned by attending physician MD B, for October 21, 2021.
· Patient 23 was admitted on July 22, 2021, with a diagnosis of Alcohol Dependence. The Inpatient Admission Orders include the order for a ClWA assessment with the detoxification protocol for a nursing observations Q2hrs (every two hours) x (for) 24Hours; Then Q4hrs (every four hours) x 24 Hrs: Then continue QShift. The CIWA form for observations made on 7/22/21 to 7/27/21, lacked/missed the observation entries for 1500, 1700, 2300 in the first 24 hours, and at 1300, 1800, 2100 on the next 24 hours, and dayshift entries on 7/25/21 and 7/26/21.
· Patient 24's telephone order by attending physician MD CO for the "CIWA Detox Orders" on admission of July 19, 2021, was unauthenticated and not signed.
· Patient 26 was admitted to the facility on August 30,2021, with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). The medical record included a physician telephone order on September 4, 2021, for a Covid test, indicated by Covid symptoms, that was not signed by physician MD B.
· Patient 26, admitted on August 30, 2021, had a physician telephone order for albuterol (medication used to prevent and treat difficulty in breathing) by inhaler for shortness of breath on September 9, 2021, which was not signed by physician MD R.
· Patient 26's record included a form titled Memorandum of Transfer on September 6, 202, that was unsigned for the Physician Certification of Transfer with the patient being sent to another hospital's emergency room.
· Patient 32's CIWA assessments for 10/28/21, were missing nursing observations at 1500, 1700, on 10/29/21 at 0700, 0900, 1100, 1300, 1700 and on 10/30/21 at 1300.

The facility DON was interviewed on 11/3/21, at 8:30 a.m., regarding Patient 32 and the discrepancies of the CIWA assessment with scores >8 (the level which required withdrawal medication to be given) on 10/28/21, at 1325, 2300 and on 10/29 at 0549 and 2100, and on 10/30/21, at 0500 that would require administration of the prescribed drug Ativan for the effects of alcohol dependency withdrawal symptoms. It was determined that a staff LVN (Licensed Vocational Nurse) had administered three (3) doses of Ativan which was documented in Patient 32's medical record while five (5) doses were removed from the pharmacy supply. The DON stated that the LVN admitted that only three (3) medication administrations were documented due to what the LVN stated was due to "laziness" and that the LVN "promised that he was giving the medication but not documenting" the medication administration in the patient's medical record. The DON stated that a disciplinary Human Resources investigation of the situation was initiated on 11/3/21, for the LVN's failure to follow the proper medication administration procedure and enter the time, dose, and medication information in the medical record. The DON was asked if the Ativan was a part of the detoxification treatment of a alcohol dependency patient and confirmed that it was.

Based on observation, interview, and record review, the hospital failed to provide pharmaceutical services that meet the needs of the patients as evidenced by:

1. The facility failed to ensure medications were administered as prescribed by the prescribers in accordance with the hospital policies and procedures, for seven patients (Patients 10, 2, 22, 34, 35, 36, and 39) (A 405);

2. The facility failed to ensure Lantus (a long acting insulin to treat high blood sugar in diabetic patients) dose was administered with two nurses to prevent dosing errors of high alert medications in accordance with the policy and procedure (A 405);

3. The facility failed to review daily medication order override reports were reviewed daily to accurately process all new medications orders for pharmacist clinical review, identify new medication orders not faxed to the pharmacy, and update patient medication profiles in the computer system and Omnicell (ADDS, automated drug dispensing system) (A 490);

4. The facility failed to maintain daily pharmacist remote medication order processing as indicated by the policy and procedure during the hours the pharmacy was closed to keep current the patients' medication profile in the pharmacy system and Omnicell (A 490);

5. The facility failed to prevent significant increase in the number of daily Omnicell medication overrides in October 2021, compared to the previous months (A 490);

6. The facility failed to ensure policy and procedure was developed and implemented in accordance with the accepted standards of practice for high-risk, high-alert medications to reduce serious medication errors (A 491);

7. One nurse (Licensed Vocational Nurse [LVN] 33) failed to account for controlled substances (CS) accessed from the Omnicell (ADDS, automated drug dispensing system) as evidenced by missing documentation of patient assessment prior to and administration of CS (A 494);

8. The facility failed to ensure pharmacists were performing the clinical review of medication orders and physicians during pharmacy after-hours consistent with the standards of practice (A 500); and

9. The facility failed to ensure multiple unusable and expired CS scheduled II to V stored in the pharmacy CS cabinet were not available for patient use (A 505).

The cumulative effect of the systemic problems resulted in the facility's failure to ensure the provision of pharmaceutical services in a safe environment that met the needs of the patients.

Based on interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the patients by failing to:

1. Review daily medication order override reports and accurately process all new medications orders after the pharmacist clinical review, identify new medication orders not faxed to the pharmacy, and update patient medication profiles in the computer system and Omnicell (ADDS, automated drug dispensing system);

2. Maintain daily pharmacist remote medication order processing as indicated by the policy and procedure during the hours the pharmacy was closed to keep current the patients' medication profile in the pharmacy system and Omnicell; and

3. Prevent significant increase in number of unnecessay and inappropriate daily Omnicell medication overrides in October 2021 compared to the previous months.

These failures had the potential for delay in pharmacy services that could affect patient care.

Findings:

1. On November 3, 2021, at 1 p.m., in an interview conducted with the Pharmacist-in-Charge (PIC), the PIC stated the Omnicell Medication Order Override Report was generated daily from Monday to Friday and reviewed for appropriateness of overrides, missing new medication orders not faxed to the pharmacy, and clinical review of medication orders. The PIC stated this review would be necessary to maintain current patient medication profile in the pharmacy computer system, Omnicell, and medication administration records (MARs).

A review of the daily override report indicated the review of the override report was not done since October 13, 2021.

In a concurrent interview, the PIC stated the contracted pharmacy company of which the PIC was an employee and the hospital entered into an agreement to not provide pharmacist remote order entry after-hours as of October 8, 2021. Since then, the PIC stated he did not have enough time to review the daily override report. The PIC further stated he was "overworked."

On November 3, 2021, at 11:30 a.m., during an interview conducted with the PIC, the PIC stated he was the only person on-call during pharmacy after-hours daily.

The facility policy and procedure titled, "New Order Handling" last revised, "05/2019" indicated:

"...When an order has not been approved by the pharmacist, Nursing services is permitted to over-ride a medication machine...to obtain a one-dose emergent drug. Pharmacy services will monitor and reconcile emergent drug transactions to ensure a valid prescriber order exists and that the right drug was administered..."

American Society of Health-System Pharmacists (ASHP), a nationally recognized pharmacy organization, represents pharmacists who serve as patient care providers in acute and ambulatory settings and is at the forefront of efforts to improve medication use and enhance patient safety.

According to "ASHP Guidelines: Minimum Standard for Pharmacies in Hospitals,

"...In the absence of 24-hour pharmacy services, access to a limited supply of medications shall only be available to authorized, licensed health care professionals for use in carrying out urgent medication orders...after-hours access shall be reviewed regularly to ensure appropriate use. The list of medications to be accessible and the policies and procedures to be used (including subsequent review of all activity by a pharmacist) shall be developed by a multidisciplinary committee of physicians, pharmacists, and nurses (e.g., by the pharmacy and therapeutics [P&T] committee or its equivalent). Access to medications should be limited to cases in which the P&T committee (or its equivalent) determines that the urgent clinical need for the medication outweighs the potential risks of making the medication accessible. The potential safety risks of medications should be considered in the decision to make them accessible, and medications, quantities, dosage forms, and container sizes that might endanger patients should be limited whenever possible..."

2. On November 3, 2021, at 1 p.m., during an interview was conducted with the PIC, the PIC stated the contracted pharmacy company of which the PIC was an employee and the hospital entered into an agreement to discontinue pharmacist remote order entry after-hours as of October 8, 2021. Since then, the PIC stated he did not have the time to review the daily override report. The PIC further stated he was "overworked."

On November 3, 2021, at 11:30 a.m., the PIC stated he was the only person on-call during pharmacy after-hours daily.

A review of the remote order entry by pharmacists schedule for October 2021, provided by the PIC, indicated one hour of pharmacist remote order entry on weekdays and six hours per weekend days in increments of two hours would be provided by the pharmacy.

The schedule also included the phone numbers of remote order entry pharmacists.

Review of the facility policy and procedure titled, "Remote Order Entry" with revised date, "10/2017," indicated:

"...A hospital pharmacy shall be authorized to utilize remote order entry when...The licensed pharmacist is not physically present in the hospital, the hospital pharmacy is closed..."

3. On November 3, 2021, at 1:50 p.m., in an interview conducted with the PIC, the PIC stated the average override was averaging about 550 between June and August, 2021, but in October the number of overrides had increased to 1309 due to the delay in reviewing the overrides and inability to update the new medication orders in the pharmacy computer system and the Omnicell.

The PIC also stated too many medications were allowed to be accessed via Omnicell override and the number of medications nursing staff could override in the absence of the pharmacist on duty would need to be limited.

On November 3, 2021, at 1 p.m., during an interviwe conducted with the PIC, the PIC stated the contracted pharmacy company of which the PIC was an employee and the hospital entered into an agreement to discontinue pharmacist remote order entry after-hours as of October 8, 2021. Since then, the PIC stated he did not have the time to review the daily override report. The PIC further stated he was "overworked."

On November 3, 2021, at 11:30 a.m., during an interview conducted with the PIC, the PIC stated he was the only person on-call during pharmacy after-hours daily.

A review of the facility policy and procedure titled, "After-Hour Medication Stock with or without Pharmacy Review" with revised date, "03/2020" indicated:

"...In the absence of a pharmacist (not on duty), the Pharmacy & Therapeutic Committee has determined that the prescriber is qualified to perform the clinical review of new orders. Nursing staff are qualified to be a second check of the order and are permitted to administer a medication under certain circumstances:

Double verification (by two nurses) (or one nurse and bar-code) is done whenever a drug is removed from an automated machine...

Specific drugs are approved for over-ride from an automated machine -
Psychotherapeutic agents (antidepressants, antipsychotics, anti-anxiety, mood stabilizers
Anti-hypertensive agents
Anti-diabetic agents
Anti-infective agents
Anti-epileptic agents
Pain-relieving agents..."

A review of the facility policy and procedure titled, "Remote Order Entry" with revised date, "10/2017" indicated:

"...A hospital pharmacy shall be authorized to utilize remote order entry when...The licensed pharmacist is not physically present in the hospital, the hospital pharmacy is closed..."

Based of interview and record review, the hospital failed to ensure policy and procedure was developed and implemented in accordance with the accepted standards of practice for high-risk, high-alert medications to reduce serious medication errors.

This failure had the potential for hospital staff to not be able to recognize the high-risk medications and take precautions to

Findings:

Review of the hospital policy and procedure titled, "High Alert Medications" last revised "09/2019," indicated:

"...High alert medications pose a risk to patient safety and must be carefully minitored and controlled. This hospital will follow special procedures when handling High Alert/High Risk Medications...

AntiCoagulants/AntiPlatelets...Warfarin/Enoxaparin will be labeled as high alert in computer systems.

Digoxin...The drug will be labeled as high alert in computer systems.

Lithium: the drug will be labeled as high alert in computer systems..."

On November 3, 2021, at 1:40 p.m., he was unable to provide evidence of high alert warnings in the hospital computer systems and how procedures related to high alert medications would be communicated to hospital staff.

Institute for Safe Medication Practices (ISMP) is a nationally recognized organization devoted entirely to preventing medication errors. According to ISMP:

"High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients. We hope you will use this list to determine which medications require special safeguards to reduce the risk of errors. This may include strategies such as standardizing the ordering, storage, preparation, and administration of these products; improving access to information about these drugs; limiting access to high alert medications; using auxiliary labels; employing clinical decision support and automated alerts; and using redundancies such as automated or independent double checks when necessary..."

Based on interview and record review, the facility failed to ensure an accurate accounting record of use of controlled substances (CS) was in place to prevent potential abuse or diversion of CS.

One nurse (Licensed Vocational Nurse [LVN] 33) was unable to account for CS accessed from the Omnicell (ADDS, automated drug dispensing system) as evidenced by missing documentation of patient assessment and administration of CS.

Findings:

A review of Patient 32's medical record indicated there was a physician's CIWA Detox(ification) Order on October 28, 2021, which included Ativan (a medication used for anxiety) 2 mg (milligram) by mouth every four hours as needed for CIWA (a tool which provided detailed and evidence-based measures for alcohol withdrawal status) score greater than or equal to eight for the treatment duration of 48 hours and hold if patient is over-sedated.

A review of the facility's policy and procedure titled, "Clinical Institute Withdrawal Assessment (CIWA) Procedure" last reviewed May 5, 2020, indicated:

"...The Clinical Institute Withdrawal Assessment Alcohol, Revised (CIWA-Ar) is designed to be an objective rating scale composed of ten criteria associated with alcohol withdrawal...

All patients are assessed upon admission for substance abuse history. Patients admitted with a recent history of alcohol abuse will be assessed for withdrawal symptoms utilizing the CIWA-Ar...

For patients admitted for alcohol detox, or identified as at-risk for detox symptoms the CIWA will be re-administered at least daily until discontinued by a physician..."

A review of the Omnicell transaction record for October 29, 2021 indicated LVN 33 accessed one dose of Ativan 2 mg three times at 9:02 a.m., 1:35 p.m., and 5:11 p.m. for Patient 32.

A review of the patient's CIWA-Ar assessment sheet and Medication Administration Record indicated the documentation was missing for the above three doses.

On November 3, 2021, at 12:50 p.m., in an interview, the Director of Nursing (DON) stated CIWA assessment would be done prior to administering lorazepam.

On November 3, 2021, at 2:45 p.m., in an interview, the DON and the Director of Quality and Compliance (DQC) confirmed missing documentation.

On November 3, 2021 at 3:45 p.m., in an interview, LVN 33 stated he administered the medication. He was not able to show documentation in the patient's chart stating the form could be floating around somewhere.

On November 4, 2021, 9:20 a.m., in an interview, the DON stated she reviewed five additional medical records of patients for whom Ativan and Librium (Scheduled IV CS used for the treatment of alcohol withdrawal) doses were accessed from the Omnicell by LVN 33 and found missing documentation for the assessment and administration.

The DON further stated LVN 33 administered the medications but was being "lazy" by not documenting the assessment and administration. The DON stated further investigation was still pending.

Based on interview and record review, the facility failed to ensure:

1. A safe process for dispensing medication was implemented when the Pharmacist delivered the second dose of Invega Sustenna (antipsychotic medication) to be administered to Patient 34 without a physician's order; and

2. The Pharmacists was performing the clinical review of medication orders during pharmacy after-hours consistent with the standards of practice.

These failures resulted in a medication error and an unsafe provision of care which may have an unfavorable effect on the patient's safety and quality of care.

Findings:

1. During a concurrent interview and record review, on October 29, 2021, at 4:10 p.m., conducted with Charge Nurse (CN) 1, Patient 34's record was reviewed. The "History and Physical" indicated Patient 34 was admitted to the facility on October 17, 2021, for psychiatric treatment.

Patient 34's "Practitioner Order Sheet," dated October 22, 2021, indicated, "...on 10/25 (October 25, 2021), start Invega Sustenna 234 mg (milligrams) IM (injection in the muscle) x (times) 1 (one)..."

There was no documented evidence the physician ordered Patient 34 to have a second dose of Invega Sustenna (for October 28, 2021).

The "Dispense Log" indicated the Pharmacist dispensed Invega Sustenna for Patient 34 on October 25, 2021, and October 28, 2021.

The "Medication Administration Record" indicated Patient 34 was administered one dose of Invega Sustenna 234 mg IM on October 25, 2021, and October 28, 2021.

CN 1 stated Patient 34 had only one physician's order of Invega Sustenna to be given on October 25, 2021.

CN 1 stated the Invega Sustenna administered to Patient 34 on October 28, 2021, did not have a physician's order. CN 1 stated it was a medication error.

During an interview on November 1, 2021, at 12:15 p.m., conducted with the Pharmacist, the Pharmacist stated he received a physician's order for Invega Sustenna 234 mg to be given IM once on October 25, 2021. The Pharmacist stated there was no physician's order for a second dose of Invega Sustenna for Patient 34.

The Pharmacist stated Patient 34's medication label for Invega Sustenna was printed twice. The Pharmacist stated Patient 34's duplicate label for Invega Sustenna was included in the medications he received on October 28, 2021.

The Pharmacist stated he did not verify if the Invega Sustenna for Patient 34 was dispensed on October 25, 2021, before delivering the medication to the nurse on October 28, 2021.

The Pharmacist stated it was his fault for dispensing the second dose of Invega Sustenna to Patient 34 without a physician's order.

The Pharmacist stated he had a lot of orders to process in a short period of time, and he did not have time to check before dispensing the second dose of Invega Sustenna to Patient 34.

During a review of the facility's policy and procedure (P&P) titled, "Medication Errors/Adverse Drug Events," reviewed in July 2020, the P&P indicated, "...Several types of medication errors exist which include...Unauthorized Drug Error: Administration to the patient of medication not authorized by a legitimate prescriber for the patient..."



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2. A review of the facility policy and procedure titled, "After-Hour Medication Stock with or without Pharmacy Review" with revised date, "03/2020" indicated:

"...In the absence of a pharmacist (not on duty), the Pharmacy & Therapeutic Committee has determined that the prescriber is qualified to perform the clinical review of new orders. Nursing staff are qualified to be a second check of the order and are permitted to administer a medication under certain circumstances:

Double verification (by two nurses) (or one nurse and bar-code) is done whenever a drug is removed from an automated machine...

Specific drugs are approved for over-ride from an automated machine -
Psychotherapeutic agents (antidepressants, antipsychotics, anti-anxiety, mood stabilizers
Anti-hypertensive agents
Anti-diabetic agents
Anti-infective agents
Anti-epileptic agents
Pain-relieving agents..."

On November 3, 2021, at 9:55 a.m., durin an interview with the Medical Director (MD), the MD stated the physicians were not performing clinical review of medication orders and the nurses would be instructed to contact the pharmacist for verification of new medication orders. He also stated the facility increased the on-call pharmacist hours just for this purpose.

On November 3, 2021, at 11:30 a.m., duirng an interview conducted with the Pharmacist-In-Charge (PIC), the PIC stated he was the only person on-call 24/7 and agreed the pharmacist should be performing the verification of orders.

The American Society of Health-System Pharmacists (ASHP), a nationally recognized pharmacy organization, represents pharmacists who serve as patient care providers in acute and ambulatory settings and is at the forefront of efforts to improve medication use and enhance patient safety.

According to "ASHP Guidelines: Minimum Standard for Pharmacies in Hospitals,"

"The pharmacy shall employ an adequate number of competent, legally qualified pharmacists to meet the specific medication-use needs of the hospital's patients...

All medication orders shall be prospectively reviewed by a pharmacist and assessed in relation to pertinent patient and clinical information before the first dose is administered or made available in an automated dispensing device, except in emergent situations in which the treatment of the patient would be significantly compromised by the delay that would result from pharmacist review of the order. There shall be a procedure for retrospective review of these orders..."

Based on observation, interview, and record review, the facility failed to ensure multiple unusable and expired controlled substances (CS) scheduled II to V stored in the pharmacy CS cabinet were not available for patient use.

These failures had the potential to expose patients to expired or deteriorated medications that could lead to ineffective treatment (such as longer hospitalization or worsening condition) for patients.

Findings:

On November 3, 2021, at 2:30 p.m., during an inspection of the CS in the pharmacy CS cabinet, the following medications were observed to be expired:

- Phenobarbital (Scheduled IV CS used for seizure) 16.2 mg (milligram, unit of measure) unit dose tablets with the expiration date of September 30, 2021;

- Chlordiazepoxide (Scheduled IV CS used for treatment for alcohol withdrawal symptoms) 5 mg unit dose capsules with the expiration date of October 31, 2021;

- Alprazolam (scheduled IV CS used for sleep or anxiety) 1 mg unit dose tablets with the expiration date, "10/21";

- One partial bottle of 100 tablets of alprazolam 0.5 mg with the expiration date, "10/21";

- Alprazolam 0.25 mg unit dose tablets with the expiration date of August 26, 2021;

- Oxycontin (Scheduled II CS narcotic used for severe pain) 10 mg unit dose tablets with the expiration date, "8/21";

- Oxycodone (Scheduled II CS narcotic used for severe pain) 15 mg unit dose tablets with the expiration date of August 31, 2021;
Oxycodone 10 mg unit dose tablets with the expiration date of October 26, 2021; and

- MS IR (Morphine Sulfate Immediate Release, Scheduled II CS narcotic used for severe pain) 15 mg unit dose tablets with the expiration date of July 29, 2021.

In a concurrent interview, the Pharmacist-in-Charge (PIC) stated all controlled substances had to be removed from the medDispense (ADDS, an automated drug dispensing system) machine because the hospital started using different ADDSs called Omnicell in September 2021. The returned CS from the old machines were placed in the pharmacy CS cabinet along with non-expired CS and logged in the current pharmacy CS inventory as returns.

The PIC further stated he was planning to go through all CS and remove the expired CS for disposal but did not have the time to clean up the inventory stating he was "overworked."

The facility policy and procedure titled, "Drug Quality Program" last revised, "09/2020" indicated:

"...Outdated/unusable drugs will be removed from active inventory and discarded appropriately...

The pharmacy staff will inspect all drug storage areas and will check for proper storage conditions, security, sanitation, and unusable medications..."

Based on interview and record review, the facility failed to ensure the initial multidisciplinary treatment plan was reviewed with the patient and/or the physician approved the treatment plan, and a follow-up treatment plan for the patient was conducted in accordance with the facility's policy and procedure (P&P), for five patients (Patients 33, 34, 35, 36, and 40).

These failures had the potential for the patients to not have a complete and individualized plan of care that meets the patients' goals and needs.

Findings:

a. During a concurrent interview and record review, on October 29, 2021, at 12 p.m., conducted with Charge Nurse (CN) 1, Patient 33's record was reviewed. The "Initial Psychiatric Evaluation" indicated Patient 33 was admitted to the facility on October 12, 2021, for a 5150 (involuntarily detained for a 72-hour period) due to grave disability.

Patient 33's "Interdisciplinary Treatment Plan Master Sheet (ITPMS)," indicated the initial treatment plan was conducted on October 14, 2021.

Further review of the ITPMS indicated, "...Staff Signatures of those involved in the Treatment Plan and Physician Approval of the Treatment Plan..." A representative from nursing, social services, and activity therapy signed the ITPMS on October 14, 2021.

There was no documented evidence the physician signed Patient 33's ITPMS conducted on October 14, 2021.

Patient 33's "Interdisciplinary Treatment Plan Update (ITPU)," indicated a follow-up treatment plan was conducted from October 19 to 21, 2021.

There was no documented evidence the physician signed the ITPU to indicate involvement in Patient 33's treatment plan update.

There was no documented evidence Patient 33 signed, refused, or was unable to sign the ITPU to indicate updates on the treatment plans were reviewed with the patient.

There was no documented evidence an ITPU was conducted for Patient 33 seven days after the last treatment plan update on October 21, 2021 (a total of eight days).

CN 1 stated all treatment plans should be signed by the patient to indicate the plan was reviewed with the patient.

CN 1 stated when the patient refused to sign or was unable to sign the treatment plan, it should be documented.

CN 1 stated treatment plans should be signed by the physician to indicate involvement and approval of the patient's treatment plan.

CN 1 stated after the initial treatment plan was conducted, a treatment plan update should be conducted by the interdisciplinary team (a group of healthcare providers from different fields who work together to manage the needs of the patients) every seven days.

b. During a concurrent interview and record review, on October 29, 2021, at 11:25 a.m., conducted with CN 1, Patient 34's record was reviewed. The "History and Physical" indicated Patient 34 was admitted to the facility on October 17, 2021, for psychiatric treatment.

Patient 34's "Interdisciplinary Treatment Plan Master Sheet (ITPMS)," indicated the initial treatment plan was conducted on October 20, 2021.

There was no documented evidence an Interdisciplinary Treatment Plan update was conducted for Patient 34 seven days after the ITPMS was completed on October 20, 2021 (a total of nine days).

CN 1 stated after the initial treatment plan was conducted, a treatment plan update should be conducted by the interdisciplinary team (a group of healthcare providers from different fields who work together to manage the needs of the patients) every seven days.

c. During a concurrent interview and record review, on October 29, 2021, at 12:20 p.m., conducted with CN 1, Patient 35's record was reviewed. The "History and Physical" indicated Patient 35 was admitted to the facility on October 12, 2021, for psychiatric treatment.

Patient 35's "Interdisciplinary Treatment Plan Master Sheet (ITPMS)," indicated the initial treatment plan was conducted on October 15, 2021.

There was no documented evidence Patient 35 signed, or refused, or was unable to sign the ITPMS to indicate the treatment plans were reviewed with the patient.

There was no documented evidence an Interdisciplinary Treatment Plan update was conducted for Patient 35 seven days after the ITPMS was completed on October 15, 2021 (a total of 14 days).

CN 1 stated after the initial treatment plan was conducted, a treatment plan update should be conducted by the interdisciplinary team (a group of healthcare providers from different fields who work together to manage the needs of the patients) every seven days.

CN 1 stated all treatment plans should be signed by the patient to indicate the plan was reviewed with the patient.

CN 1 stated when the patient refused to sign or was unable to sign the treatment plan, it should be documented.

d. During a concurrent interview and record review, on October 30, 2021, at 10:10 a.m., conducted with Social Worker (SW) 2, Patient 36's record was reviewed. The "History and Physical" indicated Patient 36 was admitted to the facility on October 21, 2021, for alcohol detoxification.

Patient 36's "Interdisciplinary Treatment Plan Master Sheet (ITPMS)," indicated the initial treatment plan was conducted on October 24, 2021.

Further review of the ITPMS indicated, "...Staff Signatures of those involved in the Treatment Plan and Physician Approval of the Treatment Plan..." A representative from nursing and social services signed the ITPMS on October 24, 2021.

There was no documented evidence the physician signed Patient 36's ITPMS conducted on October 24, 2021.

There was no documented evidence Patient 36 signed, refused, or was unable to sign the ITPMS to indicate the treatment plans were reviewed with the patient.

SW 2 stated the SWs initiated the treatment plan by meeting with the interdisciplinary team (a group of healthcare providers from different fields who work together to manage the needs of the patients).

SW 2 stated after the treatment plan was completed each team member who participated should sign. SW 2 stated the physician should sign the treatment plan to indicate approval of the patient's plan of care.

SW 2 stated the SW would then review the treatment plan with the patient and address any questions or concerns the patient might have with his or her treatment plan.

SW 2 stated when the patient refused to sign or was unable to sign the treatment plan, it should be documented.

e. During a concurrent interview and record review, on November 1, 2021, at 11 a.m., conducted with CN 1, Patient 39's record was reviewed. The "History and Physical" indicated Patient 40 was admitted to the facility on October 25, 2021, for psychiatric treatment.

Patient 40's "Interdisciplinary Treatment Plan Master Sheet (ITPMS)," indicated the initial treatment plan was conducted from October 27 to 29, 2021.

There was no documented evidence Patient 40 signed, or refused, or was unable to sign the ITPMS to indicate the treatment plans were reviewed with the patient.

CN 1 stated all treatment plans should be signed by the patient to indicated the plan was reviewed with the patient.

CN 1 stated when the patient refused to sign or was unable to sign the treatment plan, it should be documented.

During a review of the facility's P&P titled, "Interdisciplinary Treatment Plans," revised in August 2019, the P&P indicated, "...Interdisciplinary Treatment Plan Master Sheet will be completed within the first 72 hours of admission...

Patient/Legal Representative Involvement: This is signed by patient or legal representative showing their participation in developing the Interdisciplinary Treatment Plan...

Staff signatures, date and time of those involved in the treatment plan. This is to include the MD (physician) participating in the Interdisciplinary Treatment Plan Meeting...

The attending physician established the Interdisciplinary Treatment Plan for each patient, and this is evidenced by the physician's signature and date of signing on the treatment plan...

The Interdisciplinary Treatment Plan Update: Held by 7th day after admission and at a minimum of every 7 days till discharge..."

Based on interview and record review, the facility failed to ensure the patient and/or their physician signed and acknowledged the interdisciplinary treatment plan (IDTP), for three patients (Patients 11, 14, and 2).

These failures could potentially impact those patients from having individualized and achievable goals based on their psychological and medical needs, and successfully achieving those goals.

Findings:

a. On October 30, 2021, a review of Patient 11's record was conducted. Patient 11 was admitted to the facility on October 14, 2021, with a diagnosis of schizophrenia (a mental disorder involving a breakdown in the relation between thought, emotion, and behavior leading to withdrawal from reality).

An interdisciplinry treatment treatment (IDTP) meeting was conducted on October 23, 2021. The record failed to show Patient 11's physician signed the document.

An interview was conducted with the Charge Nurse (CN) 1 on November 1, 2021, at 11 a.m. CN 1 stated patient's physicians need to sign the IDTP document to acknowledge agreement with all treatment goals.

b. An interview was conducted with CN 1 on November 1, 2021, at 11 a.m. RN 1 stated the patients physician need to sign the IDTP document to acknowledge agreement with all treatment goals.

On November 2, 2021, a review of Patient 14's record was conducted. Patient 14 was admitted to the facility on October 6, 2021, with a diagnosis of a mood disorder.

The record indicated an initial IDTP meeting was conducted on October 6, 2021, and the initial goals were set. The record failed to show Patient 14's physician signed the document.



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c. During a concurrent interview and record review, on November 2, 2021, at 11:25 a.m., conducted with Social Worker (SW) 1, Patient 2's record was reviewed. Patient 2 was admitted to the facility on October 12, 2021, with a diagnosis of schizophrenia.

The "Interdisciplinary Treatment Plan Update," dated October 21, 2021, indicated, "...Changes in the Treatment Plan have been reviewed with the patient and or family/legal representative. The patient has been given the opportunity to ask questions and provide feedback...Patient Signature: (blank)...Date: (blank)...Time: (blank)..."

SW 1 stated there was no documentation Patient 2 was involved in the IDTP update on October 21, 2021.

The SW 1 stated there should be a patient signature indicating the patient was involved or documentation indicating the patient refused.

During a review of the facility's P&P titled, "Interdisciplinary Treatment Plans," revised in August 2019, the P&P indicated, "...Interdisciplinary Treatment Plan Master Sheet will be completed within the first 72 hours of admission...

Patient/Legal Representative Involvement: This is signed by patient or legal representative showing their participation in developing the Interdisciplinary Treatment Plan...

Staff signatures, date and time of those involved in the treatment plan. This is to include the MD (physician) participating in the Interdisciplinary Treatment Plan Meeting...

The attending physician established the Interdisciplinary Treatment Plan for each patient, and this is evidenced by the physician's signature and date of signing on the treatment plan...

The Interdisciplinary Treatment Plan Update: Held by 7th day after admission and at a minimum of every 7 days till discharge..."

Based on interview and record review, the facility failed to ensure complete and attested discharge summaries with patient final diagnoses and final care plans which were required within fifteen days of discharge, for eight patients (Patient 16, 18, 22, 23, 24, 25, 26, and 27).

This failure had the potential to not allow patients, their guardians, and subsequent care providers to be informed of patients discharge summary, including their final diagnoses, what care was rendered while an inpatient, discharge plans, medications at discharge and instructions upon leaving the hospital.

Findings:

During an interview on November 3, 2021, at 8:45 a.m., conducted with the Health Information Management Director (HIMD) and Health Information Management Corporate (HIMC), the HIMD and HIMC stated discharge summaries were required for all patients to be completed within 15 days of discharge.

During a review of records of patients discharged from July 2021 - October 2021, the following were noted:

· Patient 16's Physician Attestation at Discharge for August 13, 2021 was not signed to be certified as accurate and complete by the attending physician MD D.
· Patient 18's Physician Attestation at Discharge for August 25, 2021 was not signed to be certified as accurate and complete by the attending physician MD C.
· Patient 22's Discharge Summary report for October 19, 2021 was not completed as of November 4, 2021.
· Patient 22's Physician Attestation at Discharge for September 6,2021 was not signed to be certified as accurate and complete by the attending physician MD CO.
· Patient 23's Physician Attestation at Discharge for July 31, 2021 was not signed to be certified as accurate and complete by the attending physician MD G.
· Patient 24's Physician Attestation at Discharge for July 29,2021 was not signed to be certified as accurate and complete by the attending physician, and the Discharge Summary on record did not have the attestation of the attending physician MD CO.
· Patient 25's Physician Attestation at Discharge for July 26,2021 was not signed to be certified as accurate and complete by the attending physician MD C.
· Patient 26's Physician Attestation at Discharge for September 6,2021 was not signed to be certified as accurate and complete by the attending physician MD .
· Patient 27's Discharge Care Plan on October 25, 2021, was in English and signed by 2 facility RN's and not by the patient. Upon admission on 10/6/21, the Intake Assessment under "Communication Barriers or Interpreter Services" is marked 'not applicable'. Patient 27's Discharge Care Planning Summary had the entry "Pt speaks Spanish only" and he was to be discharged to "mother's home on 10/25/21. There was no indication for the need nor that translation services were used in Patient 27's medical records.
*The Medicare Message on Hospital Discharge for 10/25/21 was signed by 2 facility RN's and not translated in Spanish.
* The Discharge Plan signed by the patient on 10/25/21 was in English and signed only on the cover page for contact information.
*The Discharge Care Plan section for Discharge Medications was in English and signed by 2 facility RN's and not by the patient or representative.

During an interview on 11/4/21 at 10:20 a.m., the Director of Clinical Services (DCS) was asked how discharge planning was documented for foreign language speaking patients. The DSW stated that there was usually a Spanish speaking social worker to handle the discharge process. A sample of the Discharge Plan that could be provided to a Spanish speaking was requested and a blank form in Spanish was provided. For Patient 27, no part of the discharge summary plan nor discharge instructions were provided in Spanish, and all medical records were in English.

Based on interview and record review, the facility failed to have adequate staffing when one patient (Patient 10), was placed in four point restraints (when both legs and arms were restrained). This failure potentially resulted in Patient 10's fall and subsequently sustaining a fractured rib during the process of being restrained.

Findings:

On November 1, 2021, a review of Patient 10's record was conducted. Patient 10 was admitted to the facility on October 18, 2021, on a 5150 hold (a 72 hour involuntary hold) as the patient was deemed to be gravely disabled. Patient 10 was diagnosed with schizophrenia (a mental health disorder involving a breakdown in the relation between thought, emotion, and behavior leading to withdrawal from reality).

Further record review did not indicate Patient 10 had complaints of chest or rib pain upon admission.

A review of the "Progress Notes," dated October 19, 2021, at 7:15 a.m., indicated Patient 10 at 6:58 a.m., yelled and charged at staff, and pushed the staff against a wall. A code white (a method to call for a staff response when a violent or potentially violent person becomes unmanageable and presents as a danger to self or others) was subsequently called.

A review of the Seclusion/Restraint Packet dated October 19, 2021, at 7:15 a.m. indicated Patient 10 received: Haldol (medication used for treatment of mental health disorders) 10 milligrams (mg) intramuscularly (IM, injection in the muscle) one time (x 1); Ativan (a sedative medication) 2 mg IM x 1; and Benadryl (can be used to treat anxiety with sedative effect) 50 mg IM x 1.

During a concurrent interview and record review, on November 1, 2021, at 9:50 a.m., conducted with Charge Nurse (CN) 1, staff assignments and patient acuities were reviewed. CN 1 stated patient acuities (which determined the number of staff needed based on the severity of patients' medical status) were completed by the RNs two hours before the start of each shift. CN 1 stated the acuity number determined the same number of staff needed to care for patients on that specific unit and shift.

CN 1 stated there were not enough staff for patient care in accordance with the patient acuity for the night shift (from 7 p.m. on October 18, 2021, through 7 a.m., on October 19, 2021), as the acuity indicated six staff were required, although five staff were scheduled and working.

A concurrent interview and record review of the staffing sheet for the 7 p.m. through 7 a.m. shift was conducted on October 29, 2021, at 12 p.m., with CN 2, who worked the night shift of October 18, 2021, and was involved in Patient 10's restraint episode at 6:58 a.m., on October 19, 2021.

CN 2 stated that evening, as the charge nurse, he was assigned 12 patients on his unit (the Mission nursing unit). CN 2 further stated the Mission unit was the higher acuity unit and he also had charge nurse duties for the remaining two units in the facility. CN 2 stated other than him, there was one Licensed Vocational Nurse (LVN), two behavioral health workers (BHW), and one additional BHW who worked four hours from 3 a.m. to 7 a.m. CN 2 stated as a registered nurse, he was the only one who could assess patients. CN 2 stated there were only five staff scheduled that evening.

A follow up interview was conducted with CN 2 on October 29, 2021, at 1 p.m. CN 2 stated Patient 10 became very upset and aggressive when he told (Patient 10) he could not hold hands with another patient. CN 2 further stated at that time two of the BHW scheduled to work that shift were off of the unit and not available and just he and the other BHW were the only staff available to address Patient 10's agitation and aggression.

CN 2 stated Patient 10 became increasingly agitated, grabbed CN 2's right arm and started fighting. CN 2 stated Patient 10 then grabbed his left leg and they both fell to the floor. CN 2 stated LVN 3 was in the medication room and called the Code White but LVN 3 was afraid to come out of the medication room to help them with Patient 10.

An interview was conducted with LVN 3 on November 1, 2021, at 8 a.m. LVN 3 stated she was in the medication room when she saw a confrontation involving Patient 10, CN 2 and the BHW. LVN 3 stated there were only two staff with Patient 10 addressing the patient's aggressive behaviors because she remained in the nursing station and called for the Code White, but did not go into the hall to help CN 2 and the BHW.

LVN 3 further stated it was hard for the two staff to restrain Patient 10. LVN 3 said she prepared the emergency medication for Patient 10. LVN 3 further stated the registered nurse on the other unit "came to rescue me." LVN 3 stated then she left because it was the end of her shift.

A review of the physician's 1 documentation, dated October 26, 2021, indicated, "The patient does report that he was assaulted by the staff a few days ago and was complaining of rib pain."

A review of the results of an x-ray of Patient 10's left ribs taken on October 27, 2021, was conducted. The impression indicated a minimally displaced fracture of the posterior aspect of the left eleventh rib.

On October 30, 2021, a report from the facility was sent to the State Agency which indicated, "Patient (Patient 10) alleged that when he was placed on restraints Monday (October 18, 2021), a staff member "rammed their knee into his left ribs and hit him in the groin" while he was in four point restraints. The report did not indicate Patient 10 sustained a minimally displaced fracture of the posterior aspect of the left eleventh rib.

During a review of the facility's policy and procedure (P&P) titled, "Patient Classification/Nursing Staffing Plan," reviewed in January 2021, the P&P indicated, "...To ensure quality nursing care and safe patient environment by establishing an acuity system to determine an appropriate staffing pattern based on the assessment of patient needs...The Patient Classification Acuity form will be completed each shift by the unit RN two hours prior to the oncoming shift utilizing the guidelines on the form...The charge nurse refers to the Patient Classification Acuity form which has predetermined acuity hours appropriate for the delivery of quality nursing care...The total number of patients on each level of care is multiplied by the established number of hours, for each shift. The total number of hours will then be divided by 12 to determine the number of staff required...The necessary staffing mix will be determined by the charge nurse upon review of the patient acuity levels..."

Based on observation, interview, and record review, the facility failed to ensure a Social Worker (SW) debriefed one patient (Patient 2), after two incidents of assault by another patient in accordance with the facility's policy and procedure (P&P).

This failure resulted in a lack of interventions for Patient 2 after an assault, a traumatic event, which had the potential to result in an increased risk of Patient 2 experiencing psychological distress.

Findings:

During a concurrent observation and interview, on October 27, 2021, at 10:55 a.m., conducted with Patient 2, Patient 2 was observed to have two semicircular shaped reddened areas to his right forearm. Patient 2 stated a female patient had bit him a few days prior, but he was unsure of the exact date.

During an interview and record review, on November 2, 2021, at 11:25 a.m., conducted with SW 1, Patient 2's record was reviewed.

Patient 2 was admitted to the facility on October 12, 2021, with a diagnosis of schizophrenia (a mental health disorder which affect a patient's way to think, feel, and behave).

The nursing notes, dated October 22, 2021, at 10:15 a.m., indicated, "...female patient charged at (Patient 2) in order to harm him...managed to scratch (Patient 2) underneath L (left) eye and indent teeth on head...Medical doctor was called and ordered to clean wound and apply Neosporin (an antibacterial medication used to prevent infection)..."

The nursing notes, dated October 22, 2021, at 1:30 p.m., indicated, "...(Patient 2) was in tv (television) room when he began yelling...found female patient on (Patient 2)...It was noted that (Patient 2) had a bite mark to the right lower arm...photograph taken and put in chart..."

There was no documented evidence a SW debriefed Patient 2 after he was assaulted by another patient on October 22, 2021, at 10:15 a.m., and on October 22, 2021, at 1:30 p.m.

SW 1 stated a SW should be involved with an assessment and debriefing after a patient experiences assault by another patient. SW 1 stated there was no documentation in Patient 2's record which indicated a debriefing was provided after either of the above incidents.

During a review of the facility's P&P titled, "Patient to Patient Assault," revised in May 2021, the P&P indicated, "...In the event of a patient to patient assault, the following steps will be taken...Social Worker on that unit will meet with each patient to debrief. Staff member will document in each chart the debrief session..."