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Based on review of the medical record for Patient #1, an order for Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM now for verbal aggression, physical aggression was not administered as ordered.

Findings were:

Review of physician orders revealed that on 5-22-11 at 12 noon, Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM now for verbal aggression, physical aggression was ordered by the physician. Review of the facility Medication Administration Policy #1000.30 revealed that nursing will administer medication at the scheduled time, and the nurse handles missed doses of medication accordingly; when a patient is not able to receive a medication at the scheduled time the nurse will give the missed dose ASAP, and the nurse will check with the physician if any questions exist as to re-timing.

There was no documentation in the medical record to indicate that this medication was administered, nor was there any documentation reflecting why the medication was not administered. There was no physician or nursing documentation in the medical record to describe the verbal or physical aggression on this date. The day shift nursing note, incorrectly dated " 8-22-11 " was not timed and stated the patient was pleasant and cooperative and slept well the previous night.

Based on review of the medical record for Patient #1, the nursing skin assessment was incomplete and inaccurate, as there was no indication of the patient's bruised or blackened eye.

Findings were:

Review of the History and Physical performed by the physician assistant on 5-22-11 revealed that the patient had a right black eye and bruising. Review of the nursing skin assessment completed on 5-21-11 at 7:30 pm revealed that the patient ' s skin was directly observed and the skin was intact. There were no markings indicating any abnormalities on the physical body diagram, and specifically, no markings or other documentation by the nurse indicating a blackened or bruised area on or around the patient's eyes.

Based on interviews and observation during a tour of the facility on 7/13/2010, the facility failed to have a level of safety and quality for example - bathrooms had no soap and towels for handwashing, mattresses were in need of cleaning and multiple mattresses were torn, the floors were covered with a massive accumulation of dust when patient beds were moved, walls had holes and tiles were missing.

Findings were:

- In the dual diagnosis side the "public restroom" had tile missing and the trash was overflowing onto the floor
-The biohazard and dirty linen rooms were unsecured allowing patient entry to the restricted areas. In the biohazard room there was a strong ammonia smell, there were 3 red bag waste and two yellow bags of trash as well as dirty laundry stored on the floor
-In the clean linen room there were eggcrates opened and available for patient use, unknown if previously used, as well as trash and boxes on the floor.
- In the janitor closet, dirty mops were stored on the floor
- the sign posted in this area read "all doors must stay secured"
- In the storage room shampoo was poured into and open cup, stored bed rails were covered in dust, the floor was covered in trash and dust
-patient room #203 had four holes in the sheet rock walls, holes were observed in both the mattresses, and the tubs were not draining correctly
- patient room #205 had four holes in sheet rock, tiles were separated from the wall, one tile chipped and another tile missing, there was a leak in the tub/shower, both bed frames were covered with a layer of dust and one of the mattresses had a large, yellow/gold stain
- In room 207 a nasal cannula for the oxygen concentrator was on the floor under the bed and bugs were observed in the bathroom and shower
-in room 208 a mattress had "I died here and sex and the city" written on it in six inch letters and there was water on the floor and 2 holes in the sheet rock
-in room 206 there was a black greasy appearing spot approximately one inc square and there were six tiles separated from the wall
-in room 204 the floor was wet, there was one mattress very soiled and holes observed in walls
- In the day room the floor was observed to be in need of cleaning, and the windows were cloudy, the upholstered chairs were stained and in need of cleaning
-In the nurses station the specimen refrigerator had stains and was in need of cleaning
there were two unsecured oxygen canisters, there were dirty gloves on the floor, the AED had a substance spilled on it and was dusty, the emergency kit had no medication in it
- In the medication room the floor under the medication cart was dusty there was a lancet and the wheels of the med cart had little rubber on them making it difficult to move, there was a layer of white dust on the surfaces in the room
- In the seclusion room bathroom there was no paper or soap to wash hands; the bathroom door locked from the outside, with no window or area to visualize the patient activity; there was approximately 14 inches of baseboard pulled away from the wall in the seclusion room
additionally the entry hall to the seclusion room was used as storage for a standing scale which was in the line of traffic making it difficult to get two or three people in the area without bumping into the scale and possible injury to a combative patient
The second adult unit is described below
-In the patient kitchen door there was a sign "please this door must remain closed and locked at all times..." the door was open; the floor of the room had food drips and dried food in drawers, between the cabinets and the refrigerator there was an accumulation of plastic ware paper and dirt on the floor and the top of the refrigerator was covered in dust.
-the biohazard room had red bags on the floor
-In the laundry laundry room there was lint all over the wall nearest the dryer and there was a white powdered substance was on the floor
- in the second clean linen room wrapped linen was stored on the floor, in the supply room there were dirty gloves on the floor and hygiene items on the floor
- in room 101 there was a badly stained mattress, tile in the bathroom was pulled away from the wall, the ceiling vent sheet rock was cracked, and the air vent had an accumulation of dirt and dust
- In room 102 there was a dirty mattress in need of cleaning, there was a large accumulation of dust under the beds
-In room 103 there was a very large accumulation of dust under the beds
In the hallway outside room 103 the baseboards were separated from the wall
-In room 104 There was water draining out from the junction of the floor and the base of the toilet, there was a large amount of dust under both beds
-In room 105 the air vent had an accumulation of dirt and dust, paper trash was on the floor,
there was a very large accumulation of dust under the beds and tiles were separated from the shower walls
_In room 106 there were 12 tiles separating from the shower wall, and there was a large amount of dust under the beds
The above findings were confirmed in interviews during the tour with the Nursing director and the Director of Environmental services.

Based on review of the medical record, the treatment plan for Patient #1 revealed that the treatment plan was not updated to reflect the patient ' s disability of being wheelchair bound, and the last entry to the treatment plan was on 5-25-11, despite a need for an update to the treatment plan.

Findings were:

Review of the History and Physical performed by the physician assistant on 5-22-11 revealed that the patient reported that he had significant chronic pain in his legs as he was non-ambulatory. Review of the multidisciplinary progress note dated 5-21-11 at 8:30 pm revealed that the patient was brought to the unit in a wheelchair in handcuffs. Review of the psychiatric evaluation revealed that the patient had difficulty walking due to severe edema in his legs and was mostly wheelchair bound. Review of the Recreation Therapy Notes revealed that on 5-29-11 at 11:15 am, the patient's goal was to attend recreation therapy groups focused on social appropriateness. The activity/focus was swimming/laps. The therapist documented that the patient attended the recreation therapy group with a positive attitude; however the planned intervention was for the patient to participate in swimming of laps to promote exercise and social interaction. The documented response revealed that the patient could not get into the pool as he was wheelchair bound, so the patient sat outside in the pool area. On 5-30-11, the patient ' s treatment plan was unchanged, and the patient had the same goal and activity for swimming laps in the pool despite the patient ' s inability to participate in the activity the previous day. Additionally, the activity coordinator signed a recreation therapy note for the same swimming activity and goal on 6-2-11 stating that the patient did not show any progress toward his treatment goal as he did not attend the group activity, a day after the patient was discharged. The treatment plan goal of swimming laps in a pool was not based on an inventory of the patient ' s strengths and disabilities, nor was it updated when a disability was identified.

Review of the treatment plan for Patient #1 revealed that the treatment plan was incomplete as evidenced by no medical problems or issues listed or addressed from the patient ' s diagnosis list and no treatments or recommendations for any medical problems or issues. Additionally, the last entry was made on 5-25-11; the patient was not discharged until 6-1-11.

Interview with Staff #3 confirmed that the treatment plan was not completed or updated with regard to the patient ' s goal of swimming laps. Staff #3 stated that the patient ' s activity should have been changed as he was unable to participate due to his disability and wheelchair bound status and the treatment plan updated.