HospitalInspections.org

The Condition of Participation is NOT met as evidenced by:

Based on observation, interview, and record review, the hospital's Governing Body (GB) failed to assume full legal responsibility for implementing, and monitoring policies governing the hospital's total operation, and provide oversight for quality health care in a safe environment as follows:

1. The hospital's GB failed to ensure the medical staff requirements were met, bylaws were implemented, and the Board member collaborated in the chief executive officer CEO's hiring and annual performance evaluation process.

2. The hospital failed to meet the regulatory requirements for the Condition of Participation for Patient rights as evidenced by the hospital's GB failure to implement patient rights in accordance with acceptable standards of practice, failure to implement hospital policy and procedures with regard to use of psychotropic medications and restraints, and failure to maintain the environmental upkeep of the facility. (Cross Reference A-0115)

3. The hospital failed to meet the regulatory requirements for the Condition of Participation for Nursing Services as evidenced y the hospital's inability to ensure nursing care and services were provided in a safe manner when hospital policies and procedures (P&P) and standards of professional nursing practice regarding physical nursing assessments, pain assessments, informed consents for psychotropic medications, aftercare plans, physician's orders, staffing inaccuracies, and failure to communicate one Patient's injury to the physician. (Cross Reference Condition of Participation A-0385).

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of quality patient care in a safe environment.

Based on interview and record review, the governing body (GB) failed to ensure medical staff peer reviews were conducted per policy and procedure and to meet medical staff requirements.

These failures place patients at risk of receiving substandard care.

Findings:

During a review of the facility's policy and procedure (P&P) titled, "Peer Review-Ongoing Professional Practice Evaluation," dated 1/24, the P&P indicated, "Peer review of patient management shall occur monthly at the medical executive committee (MEC). Each clinician with privileges on the staff will have a representative sample of his/her patient activity reviewed monthly. 4. Charts screened are placed in the reviewing practitioner's charting area in Medical Records. The Peer Review form will be attached to the front of the chart. 5. Reviewing practitioner shall complete the required review documents and return them to the director of QI (quality improvement) within two weeks. The results of the review will be reported to the next monthly MEC meeting."

During a concurrent interview and record review on 10/24/24 at 9:30 a.m. with the healthcare information management consultant (HIMC), review of four medical staff credentialing files was conducted. The HIMC explained when practitioners are first appointed to the medical staff, the practitioner must have three (3) initial peer reviews, performed by another practitioner (a reviewer) to evaluate his/her professional practice, then one peer review monthly thereafter. The HIMC attaches the monthly peer review form to the patient's chart and places the chart on the assigned area for the reviewer to conduct the peer review on his/her colleague. Once the peer review form is completed, the form is returned to the QI. If there are no concerns with the peer review, then the peer review forms are placed in the practitioner's credential file. However, if there are concerns with the practitioner's peer review, then the form is forwarded to MEC for review and follow up. The HIMC further indicated the reviewer has two weeks to conduct and return the peer review forms, once received. The following was noticed during the credentialing files process.

a) Review of nurse practitioner (NP) credentialing file the HIMC reported the NP was provided temporary privileges from March 26 until August 2024, then NP's permanent privileges were approved by the governing board (GB). The NP should have the first three (3) initial peer reviews in May. Then, one peer review monthly thereafter, one for June, July, August, and September 2024. A total of seven peer review forms should be in the credentialing file. There were no peer review forms in the NP's credentialing file. The CEO produced peer review forms for the NP, all the NP peer review forms were dated 10/22/24. The HIMC stated the time frame for the reviewer to conduct the peer review and return the forms to the QI was, "Two weeks and the peer review forms produced by the CEO were late." The HIMC was asked does this mean the NP's peer review results have not been reported to MEC meetings monthly as indicated by your policy. The HIMC stated "I guess not."

b) During a concurrent interview and record review on 10/24/24 at 10 a.m. with the HIMC, Psychiatrist 2's credentialing file was reviewed. The monthly peer reviews for August 2023, January, June, July, and August 2024 were missing. The HIMC stated "The peer review forms for these months are missing, the reviewer has not returned them yet."

c) During a concurrent interview and record review on 10/24/24 at 10:30 a.m. with the HIMC, medical director (MD) credentialing file was reviewed. The initial appointment three (3) peer review forms were reviewed. Two of three peer review forms were incomplete. At the bottom of the form, there's an area where the reviewer provides his/her COMMENTS/RECOMMENDATIONS by indicating if the peer review is 1=Acceptable, 2=With reservations, 3=Committee (refer to MEC committee), or FAILED CRITERIA. This area was left blank on two of the three peer review forms. The HIMC stated, "If this area is not complete, how do we know what the reviewer recommendations were for the MD. I don't know what to tell you, this area should have been completed by the reviewer."

d) During a concurrent interview and record review on 10/24/24 at 10:50 a.m. with the HIMC, Psychiatrist 1's credentialing file was reviewed. The monthly peer reviews for February, June, July, and August 2024 were missing. The HIMC stated, "No, the peer review forms for these months are missing, the reviewer has not returned them yet."

During an interview on 10/24/24 at 12 p.m. with the medical director MD, the MD explained he is made aware of the practitioners' peer review concerns because he hears this during the MEC meetings. The MD was made aware that during the medical staff credentialing file review auditing, some concerns have been identified, where practitioner's monthly peer review forms are past due and missing from their credentialing file for numerous months.

Based on interview and record review, the governing body (GB) failed to ensure the Bylaws were implemented regarding the GB committee attendees.

This failure had the potential for the Bylaws provisions to not be implemented.

Findings:

During a review of "The [hospital's name] Board of Trustees Bylaws," dated 2/24, the "Bylaws" indicated, in ARTICLE 11, TRUSTEES, in SECTION 2.2- NUMBER AND QUALIFICATIONS, the number of members of the Board of Trustees of the Hospital shall be no less than two (2) and no more than twelve (12) ... The Board shall be composed of: the Chief Executive Officer (CEO) of the hospital; a representative of the Member as appointed by its management; the Medical Director of the hospital; the President of the Medical Staff, who shall be an ex- officio member with a right to vote; one individual who is not a member of the medical staff or employee of the Company, who represents the community served by the Hospital, ... In subpart 2.2.1 (f) "Other non-voting member attendees shall include the Director of Clinical Services and the Director of Quality Improvement of the hospital or others as designated by the Chair and approved by the Board."

During a concurrent interview and record on 10/23/24 at 3:54 p.m. with the CEO, the Bylaws, Governing Board (GB) Committee meeting minutes for November 2022, February, May and August 2024 were reviewed. The chief financial officer (CFO), chief nurse officer (CNO) and director of human resources (DHR) consistently attended the GB committee meetings. The CEO was asked if the CFO, CNO, and DHR were those "other attendees as designated by the Chair and approved by the Board", if so, can he share the GB meeting minutes where these three (3) non-voting member attendees were approved by the Board. The CEO confirmed the CFO, CNO and DHR were the other attendees as designated by the Chair and stated "No, we don't have GB minutes indicating these 3 member attendees were approved by the Board" to be part of the attendees for the GB committee meetings.

Based on interview and record review, the hospital governing body (GB) Board Member failed to:

1. Ensure the Board Member provided input in the selection of the CEO employed for the management of the hospital.
2. Ensure the Board Member participated in monitoring the performance of the CEO by collaborating and providing input which will be considered when conducting the CEO performance evaluation annually.

The hospital failures resulted in the Board Member not having the opportunity to provide input in the selection of the CEO and not providing input for his annual performance evaluations.

Findings:

1.The [hospital's name] Board of Trustees Bylaws dated 2/24, in ARTICLE V11, ADMINISTRATION, in SECTION 7.1- APPOINTMENT AND EVALUATIO, in subpart 7.1.1 indicates- Subject to input by the Board, the officers of the Member shall select and employ a ... Chief Executive Officer (CEO), using a criteria- based process ... who shall be responsible for the management of the Hospital.

During a concurrent interview and record review on 10/23/24 at 12:25 p.m., with the quality director (QD), the GB committee minutes dated 11/8/22 were reviewed. The GB minutes indicated, the CEO was appointed as the new CEO. The GB committee minutes indicated, the new CEO is already the current sitting CEO and a Board member. But, at the same time, he is appointing himself to be the CEO and Board member. The QD was asked what would happen if the Board Member disagreed with the new CEO appointment, this would be awkward because the CEO is already a sitting Board member. The Board Member is not given the opportunity to provide input for the selection of the new CEO prior to the Board member being asked to appoint the CEO. The QD stated "I know this is backwards. I don't know what to say ... [Company's name] the parent company hires the CEOs then send them to the hospital for the Board to appoint them."

During an interview with the medical director (MD) on 10/24/24 at 12:00 p.m., the MD confirmed being the medical director in November 2022, at the time, the new CEO was employed by the company. The MD was asked if he had the opportunity to participate or provide input in the selection of the new CEO as he was a member of the Board, back in 2022. The MD stated "No, I did not." The MD reported the CEO was selected and employed by the Company then the CEO was sent to be appointed by the Board.

During a concurrent review of the Bylaws and interview with the Company's regional vice president VP of operations (RVPO) on 10/25/24 at 8:45 a.m., the RVPO was asked if the Board member provided input to the company before the company employed the new CEO. The RVPO confirmed the company employed the new CEO without the Board's participation or input in the selection of the CEO.

2. The [hospital's name] Board of Trustees Bylaws dated 2/24, in ARTICLE V11, ADMINISTRATION, in SECTION 7.1- APPOINTMENT AND EVALUATIO, in subpart 7.1.2 indicates -Ongoing, the Board shall participate in monitoring the performance of the Chief Executive Officer. At least annually, the Board shall collaborate with the Company in providing input to be considered in conducting a performance evaluation for the Chief Executive Officer, which shall be done by the Company.

During an interview with the CEO on 10/23/24 at 3:54 p.m., the CEO was asked regarding his annual performance evaluation process. The CEO reported for his annual performance evaluation, he is given a self-evaluation form for him to evaluate his performance. Then, CEO meets with the regional vice president of operations (RVPO) to discuss the CEO's performance, they set goals for the upcoming year and then the RVPO signs and gives him his annual performance evaluation.

During an interview with the medical director (MD) on 10/24/24 at 12:00 p.m., the MD was asked if he has collaborated and/or provided input/feedback regarding the CEO performance to the Company for the company to conduct the CEO's annual performance evaluation. MD stated "No, I have not." The MD was asked whether he was aware if any of the Board member have collaborated in providing the Company with feedback regarding the CEO performance for this feedback to be considered when conducting the CEO's annual performance evaluation. MD stated "I don't know. I don't remember if there is a form or something like that to provide CEO's performance feedback ...the QI would know this ..."

During a concurrent review of the February, May, and August 2024 governing board (GB) meeting minutes and interview with the quality director (QD) on 10/24/25 at 3:35 p.m., the QD was asked if there was a form or something that the Board member uses to provide feedback regarding the CEO's performance for this feedback to be use for the CEO's annual performance evaluation. The QD reported a form titled "Annual Governing Board Self-Evaluation" has been recently created for the Board members to utilize to provide feedback regarding the CEO's performance. The forms were provided to the Board members during the February GB meeting. According to the August 2024 GB meeting minutes "All Board members completed the annual evaluation of the CEO." The QD was asked to share the completed forms. The QD acknowledged and confirmed that not all board members have completed the form where they evaluate the CEO performance. The QD confirmed only having one member has returned the form, the Board community member. QD stated "I know this is not good ..."

During a concurrent review of the Bylaws and interview with the Company's regional vice president VP of operations (RVPO) on 10/25/24 at 8:45 a.m., the RVPO was asked regarding the CEO's performance evaluation process. The RVPO reported conducting the CEO's performance evaluation for 2023. The process was he gives the CEO a self-evaluation form to be completed by the CEO. Then, RVPO completes a performance evaluation for the CEO. The CEO and the RVPO meet to discuss both evaluations, compare evaluations and to set goals for the next performance evaluation. Then the RVPO conducts the CEO's performance evaluation. This is how the CEO's performance evaluation was conducted in 2023. The RVPO stated "Everything is prepared and ready for his (CEO) next evaluation which is due next month in November." The RVPO was asked if the Board member have provided input on the CEO's performance for the feedback to be considered for the CEO's next performance evaluation. The RVPO stated "No, the Board member has not."

The Condition of Participation (COP) is NOT MET as evidenced by:

Based on observations, interviews, and record reviews, the hospital failed to implement and protect patient rights in accordance with acceptable standards of practice, hospital policy and procedures and failed to ensure patients received care in a safe setting when:

1. The master treatment plans (MTPs) were not updated after restraint initiation and not reviewed within seven days for one patient (Patient 201). The MTPs were incomplete for two patients (Patients 201 and 106). (Cross Reference A-130)

2. Consents to receive psychotropic medications were incomplete for five of thirty sampled patients (Patients 303, 304, 306, 102, and 106). (Cross Reference A-131).

3. A window's integrity on the door of Observation Room A was compromised. The access panel on a wall in Observation Room A was dented and had protruding bolts. The water faucet regulator on the sink in the bathroom of Observation Room B was faulty. (Cross Reference A-144)

4. Expired supplies were found in the Emergency Bag called the "Kangaroo Kit". Expired supplies were found in the medication room. (Cross Reference A-144)

5. The Emergency Kangaroo Kit and The Disaster Kit, failed to have a list of the required contents (located on the outside of the kit) that are to be stored inside the kits. (Cross Reference A-144)

6. Clean portable oxygen tanks were stored in the dirty utility room. (Cross Reference A-144)

7. Patient refrigerator had juices with no expiration date. (Cross Reference A-144)

8. Patio fence had protruding metal bolts (fasteners). (Cross Reference A-144)

9. Patient 106's master treatment plan (MTP) was not revised after patient was placed on a physical restraint. (Cross Reference A-166)

10. Vital signs were not taken during and after the use of restraint/seclusion, the Start time and Stop time were not separated between restraints and seclusion, restraint/seclusion time was not documented, and there was no event narrative about the incident that led to the restraint/seclusion for one patient (Patient 203). (Cross Reference A-167)

11. Restraint time was documented incorrectly for one patient (Patient 104). (Cross Reference A-167)

12. Restraint time was not documented, and vital Signs were not taken after the use of restraints for one patient (Patient 105). (Cross Reference A-167)

13. The physician's orders for restraint or seclusion were signed and completed within the required time frame for four patients (Patients 101, 102, 105, and 106). (Cross Reference A-168)

14. Patient 203's face to face assessment was not done within one hour of restraint/seclusion use, and Patient 101's face to face assessment was not signed and dated after restraint use. (Cross Reference A-178)

15. The registered nurse (RN) performing the one-hour face to face evaluation on Patient 105 communicated the findings of the assessment to the provider. (Cross Reference A-182)

16. Patients 201 and 202 signed the debriefing exercise when discontinuing the use of restraint or seclusion, and Patient 104's debriefing exercise was dated and timed when discontinuing the use of restraint or seclusion. (Cross Reference A-188)

17. Patient 105 was informed of the reason for the use of restraint. (Cross Reference A-188)

The cumulative effects of these systemic problems resulted in the hospital's failure to protect and promote patient's rights, and to provide quality patient care in a safe environment.

Based on interview and record review, the facility failed to follow their policy and procedure for master treatment plans (a plan for patients that establishes goals, strategies, and progress, and is used to guide their course of treatment) when:

1. The master treatment plan (MTP) was not updated after restraint initiation for one patient (Patient 201).
2. The MTP was incomplete for one patient (Patient 201).
3. The MTP was not reviewed within seven days for one patient (Patient 201).
4. The MTP was incomplete for one patient (Patient 106).

These facility failures had the potential for patients to not make progress towards treatment goals, and failed to evaluate effectiveness of interventions and modify interventions to the patients identified problems timely, and potentially failed to have patients participate in the treatment plan.

Findings:


39520

1. During a review of Patient 201's "Seclusion/Physical Restraint Record," dated 6/20/24, the "Record" indicated, Patient 201 was placed in a physical restraint at 10:10 p.m. Patient 201 came out from under a desk after much redirection and proceeded to self-harm by banging her fists into her head, requiring staff to restrain her.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 11/23, the P&P indicated in part, "V. Release from Restraint or Seclusion: The psychiatrist/provider or an RN (registered nurse) will: 10. Uses the debriefing activity to do the following: Modify the patient's treatment plan if necessary ...VI. Documentation: The attending/on call psychiatrist, provider, or RN will document: 1. Document every episode of restraint or seclusion ...2. Include information about the following: Modifications in the plan of care ..."

During a concurrent interview and record review on 10/23/24 at 12:31 p.m. with the chief nursing officer (CNO), Patient 201's MTP was reviewed. The MTP dated 6/22/24 indicated, on 6/20/24, Patient 201 was self-harming, required physical hold and IM medication. CNO verbalized the MTP is reviewed weekly unless a patient is restrained, then our practice is to update the MTP within 24 hours. The CNO acknowledged Patient 201's MTP should have been updated by 6/21/24 instead of 6/22/24.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Documentation Requirements," dated revised 8/24, the P&P indicated in part... "Clinical Services Assesssments: 16. Master Treatment Plan: a. Initial Due : Within 72 hours of admission...b. Reassessment Due: i. on day 7 of admission...ii. Every 7 days thereafter...iii. Within 24 hours after any significant incident involvong the patient..."

2. During a concurrent interview and record review on 10/24/24 at 4:24 p.m. with the staff educator (Edu), Patient 201's MTP Review dated 6/06/24, was reviewed. The MTP indicated, Patient 201's Problems/Goals were: Problem #1 Suicidal Ideation/Danger to Self, Problem #2 Alteration in Skin Integrity, Problem #3 Substance Use, Problem #4 Sexually Acting Out, Problem #5 Nicotine Replacement, Problem #6 Pain, Problem #7 At Risk for Allergic Response, Problem #8 Alteration in Nutritional Status. Each problem had associated short term goals except for Problem #3 and Problem #4. Problem #3 Substance Use goals were left blank and Problem #4 Sexually Acting Out goals were left blank. Edu acknowledged these problems/goals were not addressed on Patient 201's MTP review and was incomplete. Edu verbalized the MTP review should be filled out completely.

During a review of the facility's P&P titled, "Treatment Planning," date revised 11/23, the P&P indicated in part, "11. The Treatment Plan will be reviewed and updated as frequently as clinically indicated by the patient's anticipated length of stay and treatment issues, but at a minimum, the treatment plan is to be reviewed once a week ...12. Treatment Plan reviews and updates will include the following steps: A. Review of progress toward goals and effectiveness of interventions for each open problem on the problem list ...B. Modifications or additions made to problems/goals and interventions as appropriate ..."

3. During a concurrent interview and record review on 10/24/24 at 4:26 p.m. with the Edu, Patient 201's MTP Review dated 6/14/24, was reviewed. The previous MTP review was dated 6/6/24. The Edu verbalized the MTP is reviewed and updated weekly. Edu acknowledged Patient 201's MTP was reviewed and updated late (longer than a week, 8 days later).

During a review of the facility's policy and procedure titled, "Treatment Planning" date revised 11/23, indicated in part ... "11. The Treatment Plan will be reviewed and updated as frequently as clinically indicated by the patient's anticipated length of stay and treatment issues, but at a minimum, the treatment plan is to be reviewed once a week ..."


35399

4. During a review of the facility's P&P titled, "Treatment Planning," dated 11/23, the P&P indicated, "Each patient admitted to the hospital will have a written, individualized treatment plan. Based on assessments of clinical needs, the scope of the plan will include the patient's ... active problem list ... goals and objectives of treatment ... patient progress in meeting the goals and objectives ... treatment will be planned, reviewed, and evaluated at regular intervals by the multidisciplinary treatment team. 8. The patient's progress and current status in meeting the long- term and short- term goals and objectives of his/ her treatment plan would be regularly recorded in the patient's record ... MTP reviews. 9. Some of the listed problems may be deferred based upon problem prioritization. Reason for deferral is documented on the treatment plan."

During a concurrent interview and record review on 10/25/24 at 9:05 a.m. with the Edu, Patient 106's MTP dated 5/29/24 was reviewed. The MTP indicated, Problem # 2- Danger to Others, Problem # 3-Pain, Problem # 4- Ineffective Airway Clearance, Problem #5- Abdominal Discomfort or Gastric Distress, and Problem #6- Alteration in Nutritional Status were checked as being active, however, it was missing wether the problem was unchanged, resolved,or revised. The update section was left blank without making comments related to the patient's progress. Information was missing with these problems, therefore, making them incomplete. The Edu acknowledged and confirmed these five problems should have been completed and they were left blank. The Edu stated, "Yes, I agree the MTP is incomplete."

Based on interview and record review, the facility failed to follow their policy and procedures for informed consents of psychotropic medications (medication that affects behavior, mood, thoughts, or perception) before the administration of these medications when:

Consents to receive psychotropic medications were incomplete for five of thirty sampled patients (Patients 303, 304, 306, 102, and 106).

These failures had the potential to place patients at risk by not providing them the right to make informed decisions about receiving psychotropic medications prior to the medications being administered.

Findings:

During a review of the facility's policy and procedure (P&P) titled, "Consent for Medications, Treatments and Procedures," dated 11/2023, the P&P indicated, "Medication: The attending psychiatrist will be responsible for the informed consent procedure for psychotropic meds. This will be documented prior to psychotropic medications being given ..."

During a review of the facility's policy and procedure (P&P) titled, "Informed Consent of Psychotropic Medications", dated 11/2023, the P&P indicated, "Informed consent must be obtained from all voluntary patient, as well as all involuntary patients, before the use of psychotropic drugs ... The physician will obtain and complete the required consent upon ordering psychotropic medications ... When nursing reviews order they will determine whether a consent form has been completed ... If completed nursing will: Review medication consent for completeness ... If consent is not present or incorrect, nurse will not administer medication ..."

During a concurrent interview and record review on 10/23/24 at 12:01 p.m. with the intake director (ID), the clinical record for Patient 303 was reviewed. Patient 303's medication administration record (MAR) indicated, Gabapentin for anxiety was administered on 10/19/24, the consent for Gabapentin was incomplete, the date and time Patient 303 consented was not documented. The ID confirmed the date and time should be documented before the medication was administered.

During a concurrent interview and record review on 10/23/24 at 3:29 p.m. with the house supervisor (HS), the clinical record for Patient 304 was reviewed. Patient 304's MAR indicated, Trazodone for sleep administered on 10/17/24 and Lexapro for depression administered on 10/18/24, the consents for Trazodone and Lexapro were incomplete, the printed name of the patient, and the date and time Patient 304 consented was not documented. The HS confirmed the patient's name, date and time should be documented before the medications are administered.

During a concurrent interview and record review on 10/24/24 at 10:10 a.m. with the ID, the clinical record for Patient 306 was reviewed. Patient 306's MAR indicated, Lexapro for depression was administered on 10/22/24 and Seroquel for depression was administered on 10/22/24, the consents for Lexapro and Seroquel were incomplete, the date and time Patient 306 consented was not documented. The ID confirmed the date and time should be documented before the medications are administered.


35399

During a concurrent interview and record review on 10/25/24 at 9:51 a.m. with the ID, Patient 102's Informed Consent for Administration of Antianxiety Agents/Other Medications form dated 2/21/24 was revewed. The informed consent indicated, Ativan (treats anxiety) 1 mg by mouth twice a day as needed. The MAR indicated, patient was administered Ativan 1 mg by mouth once on 2/21/24 at 11:41 a.m. The consent form indicated this was a telephone discussion, however, the consent was not witnessed. The area where the two RNs would have signed as witnesses was left blank. The ID acknowledged and confirmed the consent form was not witnessed since it was missing the two RN's names and signatures.The ID explained when a patient refuses to sign the informed consent form but still takes the medication, two RN's must witness the consent

During a review of Patient 106's "Informed Consent form," dated 5/23/24, the "Informed Consent form" indicated, Ativan 2 mg by mouth once. The consent form indicated, "Patient refuses to sign this form but agrees to take medication." The medication administration record (MAR) indicated patient was administered Ativan 2 mg by mouth once on 5/23/24 at 11:15 p.m. The consent form indicated this was a telephone discussion and was not witnessed by anyone. In addition, the consent form was not signed by the psychiatrist until 5/30/24 at 11:15 p.m. The Edu acknowledged and confirmed the Ativan consent form was incomplete because there were no witnesses on the consent form.

During a review of Patient 106's "Informed Consent form," dated 5/29/24, the "Informed Consent form" indicated, Klonopin (treats anxiety) 1 mg by mouth twice a day as needed. Patient refuses to sign this form but agrees to take medication. The consent form indicated this was a telephone discussion, however, there was only one RN as a witness.

During a concurrent interview and record review on 10/25/24 at 9:25 a.m. with the Edu, Patient 106's Informed Consent for Administration of Antianxiety Agents/Other Medications forms dated 5/23/24 and 5/29/24 were reviewed. The Edu explained when a patient refuses to sign the informed consent form but still takes the medication, two RN's must witness the consent. The Edu acknowledged and confirmed the Klonopin consent form was incomplete because the consent form was only witnessed by one RN and there should have been two RN's witnessing the telephone informed consent discussion.

Based on observation, interview, and record review the facility failed to ensure that patients received care in a safe setting when:

1. a) A window's integrity on the door of Observation Room A was compromised.
b) The access panel on a wall in Observation Room A was dented and had protruding bolts.
c) The water faucet regulator on the sink in the bathroom of Observation Room B was faulty.

2. a) Expired supplies were found in the Emergency Bag called the "Kangaroo Kit".
b) Expired supplies were found in the medication room.

3. The Emergency Kangaroo Kit and The Disaster Kit, failed to have a list of the required contents (located on the outside of the kit) that are to be stored inside the kits.

4. Clean portable oxygen tanks were stored in the dirty utility room.

5. Patient refrigerator had juices with no expiration date.

6. Patio fence had protruding metal bolts (fasteners).

These failures placed patients at an increased risk of infection, potential harm and injury when exposed to an unsafe environment, potentially expired foods, expired supplies and potentially not prepared for an emergency.

Findings:

1a) During a concurrent observation and interview on 10/22/24 at 10:48 a.m. with a registered nurse (RN 1), during a tour of Observation Room A, located in the nursing station, a window on the door was observed to have scratches on the glass. RN 1 acknowledged the scratches and verbalized a patient must have done that with a pen or something sharp enough to scratch the glass.

During a concurrent observation and interview on 10/23/24 at 9:20 a.m., with the director of plant operations (DOPO), the window on the door to Observation Room A was observed. DOPO verbalized the scratches are on the safety film that protects the inner glass from shattering. DOPO acknowledged the integrity of the safety film on the window was compromised and verbalized should be replaced. DOPO further verbalized completes a safety grounds surveillance monthly and documents on a form.

During a review of the facility's, "Safety Grounds Surveillance Forms," dated 6/24-10/24, there was no documentation regarding the safety film on the door window in Observation Room A being scratched and needing repair.

1b) During a concurrent observation and interview on 10/22/24 at 10:50 a.m. with a registered nurse (RN 1), during a tour of Observation Room A, located in the nursing station, access panel on the wall was observed to be dented and had sharp protruding bolts. RN 1 acknowledged the protruding bolts and the potential for patient injury.

During a concurrent observation and interview on 10/23/24 at 9:18 a.m. with the DOPO, the access panel on the wall in Observation Room A was observed. DOPO verbalized the access panel looked like it had been "kicked in" and was dented. DOPO acknowledged the protruding bolts and verbalized would probably need to replace the access panel and fix the bolts.

During a review of the facility's, "Safety Grounds Surveillance Forms," dated 6/24-10/24, there was no documentation about the dented access panel in Observation Room A or protruding bolts that needed repair.

1c) During a concurrent observation and interview on 10/22/24 at 10:55 a.m. with RN 1, during a tour of Observation Room B, located in the nursing station, the sink in the bathroom was observed. The faucet was turned on and the stream of water flowed over the top of the sink, onto the surveyor shirt, and onto the floor. RN 1 acknowledged the sink faucet should be fixed.

During a concurrent observation and interview on 10/23/24 at 9:25 a.m. with the DOPO, the sink in the bathroom in Observation Room B, was observed. The sink faucet was turned on and DOPO acknowledged the stream of water flowed over the sink and onto the floor. DOPO verbalized the regulator in the faucet need to be repaired and/or replaced and further acknowledged water on the floor could be a slipping hazard.

During a review of the facility's, "Safety Grounds Surveillance Forms," dated 6/24-10/24, there was no documentation about the sink faucet needing repair in Observation Room B bathroom.

During a review of the facility's policy and procedure (P&P) titled, "Safety Walk Through and Safety Grounds Surveillance," dated 5/18, the P&P indicated in part, "To promote an environment for patients, staff, and visitors that is free from safety hazards and that all facility areas are in compliance with local and state regulations ... Safety/Hazard Inspections: A. The maintenance staff, on a quarterly basis, will complete a Safety Walk Through and on a monthly basis complete a Safety Grounds Surveillance and document this on the attached sheets ... B. All deficiencies will be noted on the forms ... C. Corrective actions taken will be noted on the forms by the maintenance staff and returned to the Safety Officer ..."

2a) During a concurrent observation and interview on 10/22/24 at 11:47 a.m., with the registered nurse (RN 1), during a tour of the medication room, an emergency bag called the "Kangaroo kit " was observed. Several supplies were observed to be inside the emergency bag. RN 1 acknowledged: a 3 ml syringe had expired in 1/31/24, a safety needle had expired in 6/2024, several alcohol pads expired in 5/2023, and two oxygen masks with tubing expired in 11/2/2023. RN 1 verbalized the expired supplies should be replaced and should not be in the emergency bag.

2b) During a concurrent observation and interview on 10/22/24 at 11:55 a.m., with the registered nurse (RN 1), during a tour of the medication room, expired supplies were found in a drawer. RN 1 acknowledged: a 3 ml syringe had expired in 3/31/24 and a safety needle had expired in 8/10/2024. RN 1 verbalized the expired supplies should be replaced and should not have expired supplies in the medication room.

During a During a review of the facility's policy and procedure titled, "Care & Maintenance of Patient Care Equipment" date revised 10/20, indicated in part, "To provide clear instructions for the care and use of patient care equipment ... Method: 3. Stock rotation and sterile supplies will be monitored monthly by Nursing Services ..."

3. During a concurrent observation and interview on 10/22/24 at 11:45 a.m. with RN 1, during a tour of the medication room, an emergency bag called the "Kangaroo kit" was observed. Several supplies were observed to be inside the emergency bag. RN 1 verbalized there is a clipboard with an "Emergency Kangaroo Bag Check Log" that is to be completed daily by nursing. Review of the clipboard with the "Emergency Kangaroo Bag Check Log," indicated, there was no list of the contents of the "Kangaroo kit". RN 1 acknowledged there was not a list of contents of what was inside the emergency bag.

During a review of the facility's "Emergency Kangaroo Bag Check Log," dated October 2024, the "Log" indicated, "... to check External Contents daily ... to check Internal Contents at the 1st of every month and when opened ... description: items match those listed in the contents list."

During a concurrent observation and interview on 10/22/24 at 11:46 a.m. with RN 1, during a tour of the medication room, a Disaster Kit was observed. RN 1 verbalized there was not a list of contents for the Disaster Kit and further verbalized plant operations maintain the Disaster Kits.

During an interview on 10/23/24 at 10 a.m. with the DOPO, DOPO verbalized maintaining the disaster kits. DOPO acknowledged there should be a list of contents located outside the Disaster Kit. DOPO further verbalized was updating all the Disaster Kits and the new kits will include a list of internal contents.

During a review of the facility's P&P titled, "Disaster Kits," date revised 3/20, the P&P indicated in part, "To ensure that the disaster kits are available and up to date when needed ... Each disaster kit will be sealed with a breakaway tie seal to ensure its contents are only used when necessary. If broken a report must be made to the maintenance staff to restock the kit and relock it. A nursing staff member reviews each disaster kit's seal monthly as part of the unit's safety walkthrough checklist. A list of contents is kept with each kit ..."

4. During a review of the facility's P&P titled, "Construction and/or Renovation," dated 8/21, the P&P indicated in part, "2.3 Utility rooms and storage areas: 2.3.2 Separate utility rooms for soiled and clean supplies are recommended ..."

During a concurrent observation and interview on 10/22/24 at 12:06 p.m. with RN 1, during a tour of the dirty utility room, two portable oxygen tanks were observed in a rack. There was a sign above the oxygen tanks indicating they were full and ready for use. There was another sign on the wall that indicated this was a dirty area. When asked if the clean portable oxygen tanks, for patient use, should be stored in the dirty utility room, RN 1 verbalized did not know. RN 1 acknowledged the dirty utility room should store dirty equipment and a clean utility room should store clean equipment and supplies.


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5. During a review of the facility's P&P titled, "Safety-Food Handling/Expiration Dates," dated 6/20, the P&P indicated, "Purpose: To establish a safety policy for handling food and expiration dates ... All items received from the food vendor will be dated with a received date and an expiration date by the dietary staff ..."

During a concurrent observation and interview on 10/22/24 at 10:55 a.m., the patient rights advocate (PRA), during a tour of Building A, a refrigerator with a sign that indicated, "Patient Use Only" was observed with 20 juices that had no expiration dates. The PRA confirmed there were no expiration dates on the juices.

6. During a review of the facility's P&P titled, "Safety Walk Through and Safety Grounds Surveillance," dated 5/18, the P&P indicated in part, "To promote an environment for patients, staff, and visitors that is free from safety hazards ..."

During a concurrent observation and interview on 10/23/24 at 9:19 a.m. with the DOPO, the DOPO acknowledged the fasteners on fencing in the Seaside Unit patio area are rusty and have rough edges, this is a patient safety issue. DPO confirmed the fasteners need to be fixed.

Based on interview and record review, the facility failed to revise Patient 106's master treatment plan (MTP) after patient was placed on a physical restraint.

This failure resulted in the MTP not reflecting the possible interventions to prevent another physical restraint episode.

Finding:

During a review of the facility's policy and procedure (P&P) titled, "Treatment Planning," dated 11/23,the P&P indicated, "The treatment plan will be reviewed and updated as frequently as clinically indicated by the patient's anticipated length of stay and treatment issues ..."

During a review of the facility's P&P titled, "Seclusion and Restraint," dated 11/23, the P&P indicated in part, V1, (2) "Document every episode of restraint or seclusion. Include information about the following ... modifications in the plan of care."

During a concurrent interview and record on 10/25/24 at 11:15 a.m. with the Chief Nursing Officer (CNO), Patient 106's clinical record was reviewed. Patient 106's "Progress Note," dated 5/24/24 at 12 a.m., indicated, patient was agitated, disruptive, kicking at staff and unable to verbally de-escalate. Patient physical restraint hold was initiated due to patient kicking at staff, screaming, and attempting to kick staff, unpredictable, and labile. The MTP Review dated 5/26/24, indicated problem #2 Danger to Others was revised at this time which was more than 24 hours. The CNO acknowledged and confirmed the MTP was not revised within 24 hours of the physical restraint episode, and it should have been since this was clinically indicated and it was a treatment issue. The CNO explained the facility's practice is that a patient's treatment plan is reviewed and updated 24 hours after a restraint/seclusion episode occurs.

Based on interview and record review, the facility failed to ensure Restraint (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely) and Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) records were complete according to policy and procedures when:

1. Vital signs were not taken during and after the use of restraint/seclusion for one patient (Patient 201).

2. a) The Start time and Stop time were not separated between restraints and seclusion for one patient (Patient 203).

b) Restraint/seclusion time was not documented for one patient (Patient 203).

3. There was no event narrative about the incident that led to the restraint/seclusion for one patient (Patient 203).

4. Restraint time was documented incorrect for one patient (Patient 104).

5. Restraint time was not documented for one patient (Patient 105).

6. Vital Signs were not taken after the use restraints for one patient (Patient 105).

These failures had the potential for harm or injury for patients when the start and stop times for restraints/seclusion were not documented correctly and when patients were not thoroughly assessed while in restraints and or seclusion.

Findings:

1. During a review of Patient 201's "Seclusion/Physical Restraint Record," dated 6/20/24, the "Record" indicated, Patient 201 was placed in a physical restraint at 10:10 p.m. Patient 201 came out from under a desk after much redirection and proceeded to self-harm by banging fists into head, requiring staff to restrain the patient.

During a concurrent interview and record review on 10/24/24 at 4:20 p.m. with the staff educator (Edu), Patient 201's medical record was reviewed. Patient 201's "Seclusion/Physical Restraint Record," dated 6/20/24, indicated, Patient 201 was placed in a physical restraint at 10:10 p.m. and ended at 10:30 p.m. The vital signs section was left blank while Patient 201 was in restraint and after the patient was released from the restraint. The Edu verbalized vital signs should be documented while a patient is in restraints unless the patient refuses and further verbalized if patient refuses, there should be documentation of refusal. Edu acknowledged Patient 201's vital signs were not documented while in restraint or post restraint and should have been.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 11/23, the P&P indicated in part, "Monitoring: Qualified staff members do the following: 2. Evaluate the patient for safety and comfort at the initiation of restraint or seclusion and minimally every 15 minutes unless otherwise noted (below). The evaluation includes any of the following, as appropriate to the patient and the type of restraint or seclusion ... Vital signs - if the patient is too agitated to tolerate vital signs initially, obtain and record vital signs as soon as possible ..."

2a) During a review of Patient 203's "Seclusion/Physical Restraint Record," dated 7/1/24, the "Record" indicated, Patient 203 was placed in a physical restraint at 10:33 a.m. Patient 203 punched a nurse in the face, kicked a therapist, spit on staff, and scratched a nurse.

During a concurrent interview and record review on 10/23/24 at 3:36 p.m. with the chief nursing officer (CNO), Patient 203's medical record was reviewed. Patient 203's "Seclusion/Physical Restraint Record," dated 7/1/24, indicated, Patient 203 was placed in a physical restraint and seclusion at 10:33 a.m. and ended at 11:11 a.m. The CNO verbalized the start time and end time was a combination of both the restraint time and seclusion time. The CNO verbalized there should be a stop and start time for each event (restraint start and stop time and then seclusion start and stop time). The CNO acknowledged the restraint and seclusion times were combined and they should have been separated.

During a review of the facility's P&P titled, "Seclusion and Restraint," dated 11/23, the P&P indicated in part, "Procedures 1. Authorizing/ordering Restraint or Seclusion: The Psychiatrist or other licensed independent practitioner (LIP) will: 4. Include the following details in all orders for restraint or seclusion: Type of restraint or seclusion, starting time, duration or anticipated ending time, indications for use ...VI. Documentation: The attending/on call psychiatrist, provider, or RN will document: 1. Document every episode of restraint or seclusion ..."

2. b) During a concurrent interview and record review on 10/23/24 at 3:38 p.m. with the CNO, Patient 203's medical record was reviewed. Patient 203's "Seclusion/Physical Restraint Record," dated 7/1/24, indicated, Patient 203 was placed in a physical restraint and seclusion at 10:33 a.m. and ended at 11:11 a.m. "The Total minutes in restraints" and "The Total minutes in seclusion" sections were left blank. The CNO acknowledged the restraint times and seclusion times were not documented and they should have been.

3. During a concurrent interview and record review on 10/23/24 at 3:39 p.m. with the CNO, Patient 203's medical record was reviewed. Patient 203's "Seclusion/Physical Restraint Record," dated 7/1/24 indicated, Patient 203 was placed in a physical restraint and seclusion at 10:33 a.m. and ended at 11:11 a.m. The section that indicated to "Describe Events, Interventions, Mental Status and Behaviors Prior to Initiation of Seclusion/Restraint" was left blank. The CNO acknowledged the event narrative that led up to using the restraint and seclusion was not documented and should have been.

During a review of the facility's P&P titled, "Seclusion and Restraint," dated 11/23, the P&P indicated in part, "VI. Documentation: The attending/on call psychiatrist, provider, or RN will document: 1. Document every episode of restraint or seclusion ... 2. Include information about the following: Circumstances that led to use ... Consideration or failure of nonphysical interventions ... Rationale for the type of physical intervention selected ..."


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4. During a concurrent interview and record review on 10/25/24 at 10:45 a.m. with the Edu, Patient 104's "Seclusion and Restraint Record," dated 3/19/24, was reviewed. The "Record" indicated, the physical restraint was started on 3/19/24 at 9:45 a.m., and ended at 10:10 a.m., the restraint duration was 25 minutes. The record documentation indicated, the total minutes patient was restrained was 5 minutes. The Edu acknowledged and confirmed the total minutes the patient was restrained was documented incorrectly.

5. During a concurrent interview and record on 10/25/24 at 9:23 a.m. with the intake director (ID), Patient 105's "Seclusion and Restraint Record," dated 4/14/24, was reviewed. Patient 105's "Physical Restraint Record," indicated, the physical restraint was started on 4/14/24 at 12 a.m., and ended at 2:45 a.m., the restraint measure duration was 2 hours and 45 minutes. The record documentation where the total minutes patient was restrained was left blank, no documentation of the time the patient was restrained was documented in the record. The ID acknowledged and confirmed the total minutes the patient was restrained should have been documented and not left blank.

6. During a review of the facility's P&P titled, "Seclusion and Restraint," dated 11/2023, the P&P indicated, "Evaluate the patient for safety and comfort at the initiation of restraint or seclusion and minimally every 15 minutes ..."

During a concurrent interview and record review on 10/25/24 at 9:23 a.m. with the ID, Patient 105's "Seclusion and Restraint Record," dated 4/14/24, was reviewed. The "Record" indicated, Patient 105 was placed on a physical restraint hold because patient was screaming, attempting to bite, hitting staff, and attempting to get inside the male's room. The restraint record indicated, the physical restraint was started on 4/14/24 at 12 a.m., and ended at 2:45 a.m. There was no evidence in the record vital signs were performed and documented for the duration the patient was restrained. The ID acknowledged and confirmed no vital signs were performed and documented for Patient 105's restrained episode.

Based on interview and record review, the facility failed to ensure the physician's orders for restraint or seclusion were signed and completed within the required time frame for four patients (Patients 101, 102, 105, and 106).

This failure placed patients at risk of being restrained without a legal restraint or seclusion order.

Findings:

During a review of the facility's policy and procedure (P&P) titled, "Transcribing Physician Orders," dated 8/2020, the P&P indicated, "All telephone orders will be received by a licensed member of the nursing staff and written as a physician's order ... Telephone orders must be authenticated by physician signature within 48 hours."

a) During a concurrent interview and record review on 10/24/24 at 3 p.m. with the chief nurse officer (CNO), Patient 101's "Seclusion and Restraint Record," dated 1/2/24, was reviewed. The "Record" indicated, Patient 101 was placed on a physical restraint hold and seclusion due to patient being delusional and hallucinating. Patient 101was attempting to attack staff. The restraint record indicated, the physical restraint and seclusion were started on 1/2/24 at 12:05 a.m., and ended 2:27 a.m., approximately 2.5 hours. The psychiatrist ordering the physical restraint and seclusion, via telephone order, did not sign and authenticate the order. The CNO acknowledged and confirmed the psychiatrist did not sign the order timely.

b) During a concurrent interview and record review on 10/24/24 at 3:40 p.m. with the CNO, Patient 102's "Seclusion and Restraint Record," dated 2/21/24, was reviewed. The "Record" indicated, Patient 102 was placed on a physical restraint hold due to patient refusing to get onto the gurney to be transferred out and discharged. The restraint record indicated, the physical restraint was started on 2/21/24 at 8:33 p.m., and ended at 8:34 p.m., (1 minute). The psychiatrist telephone order for the physical restraint was not signed until 5/12/24, approximately two and a half months later. The CNO acknowledged and confirmed the finding and stated, "Yes, the doctor should have signed the order sooner."

c) During a concurrent interview and record review on 10/25/24 at 9:23 a.m. with the intake director (ID), Patient 105's "Seclusion and Restraint Record," dated 4/14/24, was reviewed. The "Record" indicated, Patient 105 was placed on a physical restraint hold due to patient screaming, attempting to bite, hitting staff, and attempting to get inside the male's room. The restraint record indicated, the physical restraint was started on 4/14/24 at 12 a.m. and ended at 2:45 a.m. The psychiatrist telephone restraint order was not signed at all. The ID acknowledged and confirmed the psychiatrist should have signed the restraint order within 48 hours of restraint application.

d) During a concurrent interview and record review on 10/25/24 at 9:30 a.m., with the educator (Edu), Patient 106's "Seclusion and Restraint Record," dated 5/24/24, was reviewed. The "Record" indicated, Patient 106 was placed on a physical restraint hold due to being agitated, screaming, flipped over a chair, and attempting to lunge at staff. The restraint record indicated, the physical restraint was started on 5/24/24 at 12:35 a.m., and ended 12:50 a.m. The psychiatrist telephone restraint order was signed on 5/30/24 at 10:43 p.m., five days later. The Edu acknowledged and confirmed the psychiatrist should have signed the restraint order sooner, within 48 hours of restraint application.

Based on interview and record review, the facility failed to perform face to face assessments per policy and procedure for patients on Restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely) and Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) when Patients 101 and 203's face to face assessment were not done within one hour of restraint/seclusion use.

These failures had the potential for physical and psychological harm when failing to evaluate patients for safety and comfort timely.

Findings:

During a concurrent interview and record review on 10/24/24 at 3 p.m. with the chief nurse officer (CNO), Patient 101's "Seclusion and Restraint Record," dated 1/2/24 was reviewed. The "Record" indicated, Patient 101 was placed on a physical restraint hold and seclusion because patient was delusional and hallucinating. Patient was attempting to attack staff. The restraint record indicated, the physical restraint and seclusion were started on 1/2/24 at 12:05 a.m. and ended at 2:27 a.m., approximately 2.5 hours. Review of section face to face asessment indicated, the face to face assessment was conducted on 1/2/24 at 3:51 a.m., two hours later. The CNO acknowledged and confirmed these findings.

During a review of Patient 203's "Seclusion/Physical Restraint Record," dated 7/1/24, the "Record" indicated, Patient 203 was placed in a physical restraint at 10:33 a.m. Patient 203 punched a nurse in the face, kicked a therapist, spit on staff, and scratched a nurse.

During a concurrent interview and record review on 10/23/24 at 3:40 p.m. with the CNO, Patient 203's "Seclusion/Physical Restraint Record," dated 7/1/24, was reviewed. The "Record" indicated, Patient 203 was placed in a physical restraint and seclusion at 10:33 a.m. and ended 11:11 a.m. Review of section face to face assessment indicated, Patient 203 refused vital signs at 11:33 a.m. and the face to face assessment was signed by the nurse evaluator at 12:02 p.m. The CNO verbalized was unable to determine if the nurse completed the face to fact at 11:33 a.m. or 12:02 a.m. The CNO confirmed the face to face needed to be completed within the hour, and acknowledged the face to face may have been completed late.


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During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 11/23, the P&P indicated, "III. Monitoring: 2. Evaluate the patient for safety and comfort at the initiation of restraint or seclusion and minimally every 15 minutes unless otherwise noted (below) ... Physical and psychological status and comfort - a full (face to face) assessment of the patient's physical and psychological status must be complete within one hour of the initiation of the restrictive measure by a physician/provider or a trained RN with demonstrated competence in conducting the assessment ... the assessment must be completed even if the restrictive measure has been discontinued within the hour ..."

Based on interview and record review the facility failed to ensure the registered nurse (RN) performing the one-hour face to face evaluation on Patient 105 communicated the findings of the assessment to the provider.

This failure resulted in the patient's provider not being informed of the patient's status after the application of the physical restraint.

Findings:

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 11/2023, the P&P indicated, "A full face-to-face assessment of the patient's physical and psychological status must be completed within one hour of the initiation of the restricted measure by a physician/provider or a trained RN with demonstrated competence in conducting the assessment ... If the assessment is completed by an RN, he/she must also communicate findings of the assessment with the attending/on-call psychiatrist or provider as soon as possible. The assessment as well as notification of the provider must be documented."

During a concurrent interview and record review on 10/25/24 at 12:25 p.m. with the chief nurse officer (CNO), Patient 105's "Seclusion and Restraint Record," dated 4/14/24, was reviewed. The record indicated, the seclusion/physical restraint face-to-face assessment was performed by an RN, but there wa no evidence the RN consulted with the attending physician after the completion of the one-hour face-to-face evaluation. The CNO acknowledged and confirmed the RN who performed the one-hour face-to-face evaluation should have consulted with the physician and documented the consultation.

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

1. Patients 104, 201, and 202 signed the debriefing exercise when discontinuing the use of restraint or seclusion.

2. Patient 105 was informed of the reason for the use of restraint.

These failures had potential for psychological harm when not verifying the patients understanding of what behaviors led to the restraint and or seclusion incident.

Findings:

1a. During a concurrent interview and record review on 10/25/24 at 10:43 a.m. with the Edu, Patient 104's "Seclusion and Restraint Record," dated 3/19/24 was reviewed. The "Record" indicated, debriefing date and time area where the patient signs was left blank, therefore, unable to determine the date and the time the patient had signed this record. The Edu acknowledged and confirmed the date and time when the patient signed the record should have been completed.

1b. During a review of Patient 201's "Seclusion/Physical Restraint Record," dated 6/20/24, the "Record" indicated, Patient 201 was placed in a physical restraint at 10:10 p.m. due to Patient 201 coming out from under a desk after much redirection and proceeded to self-harm by banging fists into head, requiring staff to restrain patient.

During a concurrent interview and record review on 10/24/24 at 4:22 p.m. with the staff educator (Edu), Patient 201's medical record was reviewed. Review of Patient 201's "Seclusion/Physical Restraint Record," dated 6/20/24, indicated, Patient 201 was placed in a physical restraint at 10:10 p.m. and ended 10:30 p.m. Edu verbalized "The Patient Debriefing Section" (after the patient is released from restraint or seclusion) should be signed, dated, and timed by the patient. Patient 201's signature, date, and time was left blank. Edu acknowledged Patient 201 did not sign, date, or time the debriefing and should have, and further acknowledged the record was incomplete.

1c. During a review of Patient 202's "Seclusion/Physical Restraint Record," dated 6/21/24, the "Record" indicated, Patient 202 was placed in a physical restraint at 12:27 a.m. Patient 202 was trying to force way into the nurses station, yelling, running, and throwing self into a wall and exit doors. Patient 202 was yelling, was going to leave. Patient 202 was redirected to the patio and proceeded to charge at several staff members.

During a concurrent interview and record review on 10/24/24 at 4:23 p.m. with the Edu, Patient 202's "Seclusion/Physical Restraint Record," dated 6/21/24, was reviewed. The "Record" indicated ,Patient 202 was placed in a physical restraint at 12:27 a.m. and ended 12:29 a.m. Edu verbalized "The Patient Debriefing Section" should be signed, dated, and timed by the patient. Patient 202's signature, date, and time was left blank. Edu acknowledged Patient 202 did not sign, date, or time the debriefing and should have and further acknowledged the record was incomplete.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 11/23, the P&P indicated, "8. Perform a debriefing exercise with the patient following discontinuation of restraint or seclusion. This is done as soon as possible and appropriate, but no longer than 24 hours after the episode ... 9. Include the following individuals in the debriefing exercise: Patient ... Staff members who were involved in the episode ... 10. Uses the debriefing activity to do the following: Identify what led to the incident and what could have been handled differently ... Ascertain that the patient's physical well-being, psychological comfort, and right to privacy were addressed ... Counsel the patient with respect to psychological trauma that may have resulted from the incident ..."


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2. During a review of the facility's P&P titled, "Seclusion and Restraint," dated 11/2023, the P&P indicated, "V1 (2) "Informing the patient of the behavioral criteria for discontinuation of restraints or seclusion."

During a concurrent interview and record review on 10/25/24 at 9:23 a.m. with the intake director (ID), Patient 105's "Seclusion and Restraint Recor," dated 4/14/24, was reviewed. The "Record" indicated, the area of the record where it is documented, if the patient was informed of the criteria for releasing the restraint measure was left blank or unchecked. This indicated the patient was not notified of the criteria. The ID acknowledged and confirmed patient should have been notified of the criteria for releasing the restraint and this should have been documented on the record, instead it was left blank.

The Condition of Participation is NOT met as evidenced by:

Based on observation, interview, and record review, the facility failed to ensure nursing care and services were provided in a safe manner when hospital policies and procedures (P&P) and standards of professional nursing practice were not followed when:

1. The facility staff failed to contact the physician on duty to obtain further medical direction regarding an injury that resulted in a fracture for Patient 406. (Cross Reference A-398)

2. Informed consent for psychotropic (drugs that affect the brain and nervous system to treat mental illness) medication was not followed up by a doctor's signature after consent was given over the telephone for Patient 502. (Cross Reference A-398)

3. Physician was not contacted to report patient's potential injury for Patient 406. (Cross Reference A-398)

4. Discharge order aftercare plan was not performed within 24 hours of admission for Patients 302, 102 and 103. (Cross Reference A-398)

5. Admission Nursing Assessments were incomplete for three patients (Patients 104, 105, and 202). (Cross Reference A-398)

6. Physicians against medical advice (AMA) order not done for Patient 106. (Cross Reference A-398)

7. No pain assessments and reassessments were performed when pain medication was administered for Patients 101, 106, and 202. (Cross Reference A-398)

8. The automated dispensing cabinet (ADC-is a computer based system for the storage of medication) did not have labels on the medication drawer subsections. (Cross Reference A-405)

9. The medication dosage was not documented in two of 30 sampled patients (Patients 201 and 202) medical record. (Cross Reference A-405)

10. The medication waste was not documented in one of 30 sampled patients (Patient 201) medical record. (Cross Reference A-405)

11. The medication route was not documented in one of 30 sampled patients (Patient 202) medical record. (Cross Reference A-405)

12. The physicians medication order did not specify the medication route for one of 30 sampled patients (Patient 202). (Cross Reference A-405)

The effects of the facility's systemic failure to adhere to policies and procedures, standards of nursing practice and protocols resulted in the facility's inability to ensure the delivery of safe and effective nursing care services.

Based on interview and record review the facility failed to ensure licensed nurses adhered to the policies and procedures (P&P) of the hospital when:

1. Informed consent for psychotropic (drugs that affect the brain and nervous system to treat mental illness) medication was not followed up by a doctor's signature after consent was given over the telephone for Patient 502.
2. Physician was not contacted to report patient's potential injury for Patient 406.
3. Discharge order aftercare plan was not performed within 24 hours of admission for Patients 302, 102 and 103.
4. Admission Nursing Assessments were incomplete for three patients (Patients 104, 105, and 202).
5. Physicians against medical advice (AMA) order not done for Patient 106.
6. No pain assessments and reassessments were performed when pain medication was administered for Patients 101, 106, and 202.

These failures had the potential in not ensuring the delivery of the best care possible and also potential health and safety risks.

Findings:

1.During a review of Patient 502's "Face sheet," dated 10/15/24, the "Face sheet" indicated, "Patient 502 was a 64-year-old female admitted to psychiatric hospital on 10/15/24 on a voluntary basis and admitted for Major Depressive disorder, with psychotic symptoms. Discharged 10/18/24."

During a review of Patient 502's "Consent for The Administration of Antidepressant Medication(s) (Consent)," dated 10/15/24, the "Consent" indicated, Trazodone (medication used to treat depression) 100 mg (milligrams) PO (by mouth) QHS (at bedtime) for sleep. One nurse obtained informed consent over the phone by psychiatrist. Another nurse witnessed informed consent given over the phone by psychiatrist. No physician signature noted.

During an interview on 10/24/24 at 11 a.m. with Chief Nursing Operator (CNO), CNO acknowledged the consent should have been signed by the physician.

During a review of the facility's policy and procedure (P&P) titled, "Informed Consent of Psychotropic Medications," dated 11/23, the P&P indicated, "Procedure: 1. The physician will obtain and complete the required consent upon ordering psychotropic medications 2. When nursing reviews order they will determine whether a consent form has been completed. a. If completed nursing will: Review medication consent for completeness."

During a review of the policy and procedure titled, "Transcribing Physician Orders," dated 8/20, indicated, "Policy: It is the policy of Vista del Mar Hospital to accept and carry out written and telephone orders for medication related orders and treatments ... 2. Telephone orders F. Telephone orders must be authenticated by physician signature within 48 hours."

2. During a review of Patient 406's "Nursing Progress Notes (NPN)," dated 7/18/24, the "NPN" indicated, at approximately 3 p.m. Patient 406 punched the wall with a closed fist. The incident was reported to the House Supervisor (HS) by Registered Nurse 1 (RN 1). The "NPN" further indicated, the HS instructed RN 1 to "contact internist for further orders."

During an interview on 10/23/24 at 10:15 a.m. with HS, HS confirmed verbalizing during an interview on 8/27/24 at 4:24 p.m., the usual process would be to contact the on-call physician. It's not us up to us to determine if the injuries are more than what they appear. The physician was not contacted and should have been. the nurse was instructed to do so and did not.

During an interview on 10/23/24 at 1:30 p.m. with the Director of Quality Improvement (DQI), the DQI confirmed verbalizing during an interview on 8/23/24 at 11:35 a.m., the physician was not contacted. The nurse has been reprimanded; he definitely should have been notified for further instructions.

During a review of the facility's policy and procedure (P&P) titled, "Medical Emergencies," dated 9/18, the P&P indicated, "The physician on site or on call at the time of the patient's evaluation will provide medical direction to the nursing staff conducting the medical evaluation."


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3. During a review of the facility's P&P titled, "Assessment and Documentation Requirements," dated 8/2024, the P&P indicated, "Discharge Order/Aftercare Plan ... development starts within 24 hours of admission and evolves throughout the patient's stay ..."

a) During a concurrent interview and record review on 10/24/24 at 12:30 p.m. with the staff educator (Edu), Patient 302's clinical record was reviewed. Patient 302's nursing admission assessment, dated 10/18/24, indicated, Patient 302 was admitted on 10/18/24 at 2:48 p.m. Patient 302's discharge order/aftercare plan indicated the discharge aftercare plan was initiated on 10/21/24 at 9:30 a.m., which was not within 24 hours of patient's admission. The Edu acknowledged and confirmed the discharge aftercare plan for Patient 302 was not initiated within 24 hours of admission.

b) During a concurrent interview and record review on 10/25/24 at 10:25 a.m. with the CNO, Patients 102 and 103's Discharge Order/Aftercare Plans were reviewed. Patient 102's nursing admission assessment, dated 2/19/24 indicated, patient was admitted on 2/19/24 at 11:58 p.m. Patient 102's discharge order/aftercare plan indicated, the discharge aftercare plan was initiated on 2/21/24 at 11:36 a.m., which was not within 24 hours of patient's admission. Patient 103's nursing admission assessment, dated 3/16/24 indicated patient was admitted on 3/16/24 at 10:05 p.m. Patient 103's discharge order/ aftercare plan indicated the discharge aftercare plan was initiated on 3/19/24 at 7:39 p.m., which was not within 24 hours of patient's admission. The CNO acknowledged and confirmed the discharge aftercare plans for Patients 102 and 103 were not initiated within 24 hours of admission.


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4. During a review of the facility's P&P titled, "Treatment Planning," dated 11/23, the P&P indicated, "Within 8 hours of admission, the RN will initiate the initial treatment plan located in the nursing assessment. This plan will include high risk and critical medical problems, appropriate nursing interventions as determined by the Intake and Nursing Assessment, and collaboration directed by the admitting physician's orders."

a) During a concurrent interview and record review on 10/25/24 at 10:15 a.m., with the Edu, Patient 104's Nursing Admission Assessment dated 3/15/24 was reviewed. The nursing assessment initial treatment plan with the problem for suicidal ideation was initiated. There were no interventions documented for suicidal ideation. The Edu confirmed the initial treatment plan was incomplete, thus making the nursing assessment incomplete as well. Edu stated "Yes, this is incomplete because there are no interventions listed for implementation for this problem."

b) During a concurrent interview and record on 10/25/24 at 9:23 a.m. with the intake director (ID), Patient 105's Nursing Admission Assessment dated 4/10/24 was reviewed. The nursing assessment review of systems section was left blank for the central nervous system, cardiovascular and head, ear, nose, and throat (HEENT) systems. The ID acknowledged and confirmed the assessment was incomplete and verbalized all the systems sections should have been documented as part of the nursing assessment.

c) During a review of Patient 202's "Nursing Admission Assessment" dated 6/21/24 indicated Patient 202 was admitted for suicidal ideation and auditory hallucinations.

During a concurrent interview and record review on 10/23/24, at 4:26 p.m., with the chief nursing officer (CNO), Patient 202's "Nursing Admission Assessment," dated 6/21/24 was reviewed. The learning assessment section was left blank. The CNO acknowledged there was no documentation in Patient 202's learning assessment section and should have been filled out. The CNO further verbalized the assessment was incomplete.

5. During a review of the facility's P&P titled, "A.M.A. (Against Medical Advice) Discharge," dated 10/23, the P&P indicated, "When a patient does not meet the criteria for legal hold ... or request to be discharged AMA, the procedure for discharge is as follows ... c. If the patient still wants to leave AMA, the psychiatrist assigned to the patient will write a discharge AMA order ..."

During a concurrent interview and record review on 10/25/24 at 11 a.m. with the CNO, Patient 106's record and the facility's P&P titled, A.M.A. (Against Medical Advice) Discharge were reviewed. The CNO explained the patient was discharged against medical advice (AMA) on 6/13/24. The CNO was unable to produce the psychiatrist discharge order for Patient 106 and stated, "No, there is no discharge AMA order from the psychiatrist for this patient, its missing."

6. 6. During a review of the facility's P&P titled, "Pain Assessment/Management and Safe Opiate Prescribing," dated 7/23, the P&P indicated, "A pain assessment will be completed at any time the patient has a complaint of pain or demonstrate any pain behaviors. Reassessment of a patient's pain is done by nursing staff as follows and documented on the nursing progress note ... If a patient receives oral pharmacologic or non-pharmacologic interventions the reassessment of the patient's pain level will be completed within one hour using the same pain scale that was initially used ..."

a) During a concurrent review of Patient 101's medical record and interview with the CNO on 10/25/24 at 10:35 a.m., Patient 101's Nursing Admission Assessment dated 1/1/24 indicated, patient complaint of back and arms pain, rating the pain 8 out of 10 on a 1-10 pain scale. Patient 101's "Medication Administration Record (MAR)," indicated, patient was administered Tylenol (pain medication) 650 milligrams by mouth for arms and back pain on 1/1/24 at 9:30 p.m. There was no pain reassessment conducted after the administration of the Tylenol medication. The CNO acknowledged and confirmed a pain reassessment should have been conducted by the nurse. CNO stated "Yes, I agree the pain assessment should have been done and documented in the record by the nurse."

b) During a concurrent interview and record on 10/25/24 at 10:05 a.m. with the Edu, Patient 106's MAR) was reviewed and indicated the following when Patient 106 was administered:

i. Excedrin (pain medication) I tab by mouth on 6/9/24 at 12:39 p.m. There was no pre pain assessment before the Excedrin was administered and there was no post assessment one hour after the Excedrin was administered.
ii. Ibuprofen (pain medication) 600 milligrams (mgs) on 6/10/24 at 3:15 p.m. There was no pre pain assessment performed before the ibuprofen was administered.
iii. Tylenol (pain medication) 650 mgs on 6/11/24 at 6:02 a.m., without a pre and post pain assessment for medication administration.
iv. Tylenol 650 mgs on 6/11/24 at 8:12 p.m., again without a pre pain assessment for medication administration.
The Edu acknowledged and confirmed these medications were administered without the appropriate pain assessments and reassessments.

c) During a concurrent interview and record review on 10/23/24 at 4:26 p.m. with the Edu, Patient 202's "Acute Nursing Progress Note," dated 6/21/24 was reviewed. Patient 202's progress note indicated, at 8:30 a.m., Patient 202 had a headache, 2/10 on the pain scale score. and was not on any routine pain medications. The time of the pain reassessment and the pain-scale score was left blank. Edu verbalized the patient should have been reassessed for pain. Edu acknowledged there was no documentation of a pain reassessment.

Based on observation, interview, and record review the facility failed to follow policy and procedures and nursing standards of practice when:

1. The automated dispensing cabinet (ADC-is a computer based system for the storage of medication) did not have labels on the medication drawer subsections.

2. The medication dosage was not documented in two of 30 sampled patients (Patients 201 and 202) medical record.

3. The medication waste was not documented in one of 30 sampled patients (Patient 201) medical record.

4. The medication route was not documented in one of 30 sampled patients (Patient 202) medical record.

5. The physicians medication order did not specify the medication route for one of 30 sampled patients (Patient 202).

These failures had potential for medication errors and potential for patient harm when not knowing if patients received the correct medication dosage via the correct route.

Findings:

1. During a review of the facility's policy and procedure (P&P) titled, "Pharmacy Automation: Med-Dispense System-Medication Restock," date reviewed 2/24, the P&P indicated in part, "The Pharmacy will maintain an established procedure to assure the integrity and responsibility of correct medication distribution throughout the facility ... Procedure: 4.6 Medications will be safely and accurately restocked in the med-dispense distribution system. To prevent errors, each drawer subsection will be labeled with the name displayed on the screen when the drawer is open. For example, if the screen shows section A, the corresponding drawer subsection will be labeled "A" ..."

During a concurrent observation and interview on 10/22/24 at 11:25 a.m. with a registered nurse (RN 1), during a tour of the medication room, an automated dispensing cabinet (ADC) was observed. RN 1 demonstrated how to use the ADC by pulling out a medication (Blistex lip balm). The display screen indicated Blistex was in drawer number "67" and to pull from subsection "B". When the labeled drawer number "67" opened there were four different subsections in the drawer. The subsections were not labeled with A, B, C, or D and/or the name of the medication. RN 1 verbalized "A" starts from the front and are sequential to the back (A, B, C, D). When asked if there was a possibility of pulling the wrong medication when the subsections were not labeled, RN 1 acknowledged pulling the wrong medication could happen and verbalized it would be helpful if the subsections were also labeled.

During an interview on 10/24/24 at 10:06 a.m. with the director of pharmacy (DOP), DOP verbalized pharmacy is responsible for restocking the ADC and making sure the medications are restocked in the correct drawers. When informed of the subsections not being labeled with A, B, C, D and/or the name of the medication, DOP acknowledged there was a possibility of pulling the wrong medication. DOP further acknowledged it would be helpful to nursing if the subsections were labeled.

2. Review of Potter and Perry, Tenth Edition, Fundamentals of Nursing, page 609 in the section titled, "Medication Administration" indicated in part, "After administering a medication, immediately document which medication was given on a patient's medication administration record (MAR) per agency policy to verify that it was given as ordered ..."

During a review of the facility's P&P titled, "Medication Administration," date revised 10/20, the P&P indicated in part, "9. Medication Documentation: Documentation is to occur immediately after administration ... c. STAT (immediately) and Emergency doses are documented on the PRN (when needed) MAR and indicated by the time the dose was administered. Indication and response should be indicated in the progress notes. STAT and Emergency dose orders are to be administered within 30 minutes ..."

a) During a concurrent interview and record review on 10/23/24 at 11 a.m. with the chief nursing officer (CNO), Patient 201's medical record was reviewed. Patient 201's physician medication order dated 6/20/24 indicated, "STAT (immediately) OLANZapine (an antipsychotic medication - Zyprexa) Intramuscular (IM) Solution Reconstituted 10 mg (Zyprexa 10mg IM): [5mg Intramuscular inject once now for 1 Day], Rationale/ Emergency Medication - danger to self (banging head under desk)." Patient 201's medication administration record (MAR) dated 6/20/24 indicated, a nurse gave Zyprexa at 10:28 p.m. but the dosage was not documented. When asked if the nurse gave Zyprexa 10 mg IM or 5 mg IM, the CNO verbalized she gave the 5mg IM of Zyprexa. When asked where Zyprexa 5 mg IM is documented, the CNO verbalized on the MAR. When informed the MAR only had the time the medication was given and not the dose, the CNO acknowledged the dosage amount was not documented on the MAR. When asked how we know the nurse gave 5 mg of Zyprexa instead of the 10 mg of Zyprexa, the CNO verbalized did not know but could look at a progress note.

During a concurrent interview and record review on 10/23/24 at 11:05 a.m. with the CNO, Patient 201's "Progress Note" dated 6/20/24 at 11 p.m., was reviewed. Patient 201's progress note indicated, Patient 201 was given IM medications, restrained, and assessed for a hold. The progress note further indicated, staff had to hold Patient 201 down to give the IM injection and the medication became effective within 15 minutes. CNO acknowledged the nurse did not document the actual dose of Zyprexa on the progress note and further acknowledged it should have been documented somewhere in Patient 201's medical record.

b) During a concurrent interview and record review on 10/24/24 at 10:50 a.m. with the quality director (QD) and the staff educator (Edu), Patient 202's medical record was reviewed. Patient 202's physician medication order dated 6/21/24 indicated, "[NOW] LORazepan (an antianxiety medication - Ativan) Oral Tablet 2 MG (Ativan) (Ativan TAB 2MG: 2 mg injectioon X1 once Now) Inject once NOW. Rationale / Indication: emergency medication d/t (due to) unsafe behavior-throwing self to ground and screaming." Patient 202's MAR dated 6/21/24 indicated, a nurse gave Ativan at 12:28 a.m. but the dosage was not documented. The QD and Edu both verbalized they did not know if the nurse gave Ativan 2 mg oral or Ativan 2 mg injection. The QD and Edu both acknowledged the dosage amount was not documented on the MAR and it should be.

During a review of the facility's P&P titled, "Transcribing Physician Orders," date revised 8/20, the P&P indicated in part, "4. Transcribing Medication Orders and Medication Related Orders: E. STAT or Emergency Doses are documented on the PRN MAR ... i. Medication name, dosage, route, indication, and time to be given will be noted ..."

3. During a concurrent interview and record review on 10/23/24 at 11 a.m. with the CNO, Patient 201's medical record was reviewed. The physician medication order dated 6/20/24 indicated to give Zyprexa 10 mg (an antipsychotic medication) intramuscular (IM) and [5mg IM inject once now], rationale/ emergency medication-danger to self (banging head under a desk). The MAR dated 6/20/24, indicated, a nurse gave Zyprexa at 10:28 p.m. but the dosage was not documented. When asked if the nurse gave Zyprexa 10 mg IM or 5 mg IM, the CNO verbalized she gave the 5 mg IM of Zyprexa. When asked where the Zyprexa 5 mg waste is documented, the CNO verbalized the medication waste is not documented in the MAR. When asked how we know the nurse gave 5 mg of Zyprexa instead of the 10 mg of Zyprexa, the CNO verbalized medications are wasted in the automated dispensing cabinet (ADC). When asked if there was any documentation in Patient 201's medical record that Zyprexa 5 mg was wasted, the CNO verbalized no. The CNO verbalized the medication waste should get recorded in a report from the ADC. The CNO acknowledged there was no documentation of Zyprexa 5 mg wasted in Patient 201's medical record and further acknowledged the medication waste was only recorded in the ADC report.

Review of Potter and Perry, Tenth Edition, Fundamentals of Nursing, page 365 in the section titled, "Informatics and Documentation," indicated, "Documentation is a key communication strategy that produces a written account of pertinent data, clinical decisions and interventions, and patient responses in a health record. Documentation in a patient's health record is a vital aspect of nursing practice."

During a review of the facility's policy and procedure titled, "Medication Administration," date revised 10/20, indicated in part ... "Procedure: Medication Administration: 3. Unused and Questionable Medications: b. Unused opened non-controlled medications are to be wasted per pharmacy guidelines ..."

4. During a review of the facility's policy and procedure titled, "Transcribing Physician Orders" date revised 8/20, indicated in part ... "4. Transcribing Medication Orders and Medication Related Orders: E. STAT or Emergency Doses are documented on the PRN MAR ...i. Medication name, dosage, route, indication, and time to be given will be noted ..."

During a concurrent interview and record review on 10/24/24 at 10:50 a.m. with the quality director (QD) and the staff educator (Edu), Patient 202's medical record was reviewed. The physician medication order dated 6/21/24 indicated, to give Ativan 2 mg (an antianxiety medication) oral tablet and [2 mg injection inject once now], rationale/ emergency medication-due to unsafe behavior-throwing self to ground and screaming. The MAR dated 6/21/24 indicated, a nurse gave Ativan at 12:28 a.m. but the route was not documented. There was no route documented. The QD and Edu both verbalized they did not know which route the Ativan was given. The QD and Edu both acknowledged the route was not documented on the MAR and it should be.

During further review of Patient 202's MAR dated 6/21/24, the MAR indicated, to give Benadryl 50 mg intramuscular (IM) [50 mg IM inject once now] and to give Haldol 5 mg intramuscular (IM) [5 mg IM inject once now], rationale/ emergency medication-due to unsafe behavior-throwing self to ground and screaming. The MAR indicated a nurse gave the Benadryl and Haldol at 12:28 a.m. but the route was not documented.

During a review of Patient 202's "Seclusion/Physical Restraint Record," dated 6/21/24 at 12:27 a.m., the "Seclusion/Physical Restraint Record" indicated, the on-call physician was contacted and gave orders for restraint and emergency IM medications. Patient 202 had to be held down for about 2 minutes to safely administer medications. There was no documentation that indicated Ativan 2 mg was given oral or IM, no documentation that indicated Benadryl 50 mg was given IM and no documentation that indicated Haldol 5 mg was given IM. The medication routes were not documented in Patient 202's medical record.

Review of Potter and Perry, Tenth Edition, Fundamentals of Nursing, page 609 in the section titled, "Medication Administration" indicated in part ... "After administering a medication, immediately document which medication was given on a patient's medication administration record (MAR) per agency policy to verify that it was given as ordered ..."

5. Review of Potter and Perry, Tenth Edition, Elsevier, Fundamentals of Nursing, page 609 in the section titled, "Medication Administration," indicated, "If there is any question about a medication order because it is incomplete, illegible, vague, or not understood, contact the health care provider before administering the medication."

During a concurrent interview and record review on 10/24/24 at 10:50 a.m. with the QD and the Edu, Patient 202's medical record was reviewed. The physician medication order dated 6/21/24 indicated, to give Ativan 2 mg oral tablet and [2 mg injection inject once now], rationale/ emergency medication-due to unsafe behavior-throwing self to ground and screaming. The Ativan 2 mg injection did not specify what kind of injection (IV-intravenous, SQ-subcutaneous, or IM-intramuscular). QD and Edu both acknowledged the injection route was not specified in the physician's order and it should be.

During a review of the facility's P&P titled, "Transcribing Physician Orders," date revised 8/20, the P&P indicated, "Written Orders: ... C. Written orders for medication will be implemented if they include the following: Date, Time, Medication Strength, Route, Frequency,, including daily maximum dose for PRN (as needed) medications, Indication for all PRN medication, and Physician's signature ...3. Clarification of Orders: A. If the physician is present, the licensed staff will ask the physician to clarify the order. The physician will write the clarification as such as a Physician's Order ..."