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Based on policy and procedure review, grievance file review, and staff interview the hospital staff failed to describe the steps taken on behalf of the patient to investigate the grievance or the outcome of the investigation per policy for 1 of 2 grievance files reviewed (Files #1).

Findings included:

Review on 05/25/2018 of the Hospital Policy, "Review and Resolution of Complaints ...", revised 09/13/2016, revealed " ...Time Frame for Resolution ...the Privacy Complaint Committee must investigate the underlying circumstances ... Unless the complaint is anonymous, ...the Privacy Complaint Committee must provide a written response to the individual who submitted the privacy complaint containing the following information: ... "The name of the contact person at the Regional Corporate Responsibility Office or at (Hospital) who will answer questions relating to the investigation and resolution of the privacy complaint; "A general description of the steps taken to investigate the privacy complaint; and "An explanation of the (Hospital) resolution regarding the privacy complaint. ..."

1. Review of Grievance File # 1 revealed the grievance was received on 03/28/2018. Review revealed "... (Family Member) concerned with patient care." File review revealed a letter, dated 03/29/2018, that stated, "...Thank you for contacting us regarding your concerns with (patient's) visit here at (Hospital). After speaking with you, I have logged the concerns you expressed as a formal complaint, will interview staff and review (patient's) record. Once we complete the investigation, we will respond back to you in 7 to 14 business days with the findings. ..." Letter review did not reveal the name of a contact person in the Regional Corporate Responsibility Office or at (Hospital) available to answer questions relating to the investigation and resolution of the complaint per policy. File review revealed a second letter, dated 04/10/2018, that stated "...Thank you for the opportunity to look into the concerns you shared with us regarding (patient's) visit here at (Hospital). As promised, we opened a formal complaint. We have shared your feedback with our staff to help them understand your perception of care, why you felt that way, and ways we could improve this experience for you and (patient). ...This is why we appreciate when our patients and their families alert us to any concerns they have. ...Your voice is essential to making positive changes not only the medical care but also the personal and spiritual care we give. ..." Letter review did not reveal a description of the steps taken on behalf of the patient to investigate the complaint nor the outcome of the investigation.

Interview on 05/25/2018 at 1300 with the Accreditation Manager (AM) and Director of Patient Safety (DPS) revealed the grievance response letter did not include all the required components listed in the policy.

Based on policy and procedure review, the hospital's internal log of restraint/seclusion related deaths, medical record review and administrative staff interview, the hospital staff failed to place the primary diagnosis(es), date of birth, and name of the attending physician for a patient who expired within 24 hours of soft wrist restraints and failed to make an entry into the medical record of the date and time the death was recorded on the internal log per CMS regulatory requirements for 1 of 1 deaths records reviewed (Patient #3).

Findings included:

Review on 05/25/2018 of the Hospital Policy, "USE OF RESTRAINTS", revised 04/05/2018 revealed "...H. Death Reporting 1. Patient deaths that occur...2. Excluded are patients in only soft wrist restraints where no seclusion was used; these deaths will be logged and provided to CMS upon request. ..."

Review on 05/25/218 of the hospital's internal log of patient deaths while in bilateral soft wrist restraint or within 24 hours of use, revealed Patient #3 was admitted on 03/01/2018 and expired 03/06/2018, with the last documented restraint use date noted as 03/06/2018. Review revealed bilateral soft wrist restraints were in use when the patient expired. Review failed to reveal the date and time of entry to the internal log. Further review revealed the primary diagnosis(es), date of birth, and name of the physician/licensed independent practitioner (LIP) responsible for the care of the patient.

Closed medical record review on 05/25/2018 for Patient #3 revealed an 80 year-old was admitted on 03/01/2018 at 0247 after she fell out of bed and developed a change in mental status with "expressive aphasia". Review of the ED physician progress note revealed, "She is somewhat obtunded, she does not open her eyes or respond to any verbal or tactile stimuli. ...DIAGNOSTIC IMPRESSION: 1. Metabolic encephalopathy on presentation worrisome for stroke. ..." Review revealed the patient was placed in bilateral soft wrist restraints on 03/02/2018 at 1704 and released on 03/06/2018 at 1357. Review revealed the patient expired on 03/06/2018 at 1357 while in bilateral soft wrist restraints (~93 hours). Record review on 05/25/2018 (18 days after patient expired) failed to reveal documentation of the date and time the death was recorded on the internal log.

Interview on 05/24/2018 at 1130, with the DPS revealed there is an internal log kept for recording deaths when a patient is in restraints or within 24 hours of restraints. Interview revealed Patient #3 expired within 24 hours of being in a restraint and that the primary diagnosis(es), date of birth, and name of the attending physician were not included on the log. Interview revealed that after review of the record, hospital staff could not find an entry into the medical record of the date and time the death was recorded on the log. Interview confirmed the above findings.

Based on review of facility policies and procedures, 2018 Performance Improvement Plan, medical records, incident logs and staff interviews, facility staff failed to ensure adverse patient events were entered into the hospital's "Occurrence Reporting" database 5 of 5 incidents involving patient-to-patient aggression for 1 of 1 records reviewed with incidents (Patient #7).

Findings included:

Review on 05/24/2018 of the hospital policy, "OCCURRENCE REPORTING", revised 02/13/2018, revealed "... POLICY...It is the policy of (Hospital) to report quality and safety incidents to the Patient Safety/Risk Management Department... DEFINITIONS: Occurrence - Anything not expected in the desired care for patients... Minor: - Insignificant or non-disabling injury. ...1. Patient Injury A. If an adverse event occurs... C. An Occurrence Report is then completed as soon as possible, but will always within the work shift of the occurrence... All occurrence reports are to be completed in RiskMaster. ..."

Review on 05/25/2018 of the hospital's policy, "PATIENT RIGHTS AND RESPONSIBILITIES", revised 04/16/2014, revealed "... The patient has a right to receive care in a safe setting..."

Review on 05/25/2018 of the hospital's "PERFORMANCE IMPROVEMENT PLAN" for 2018 revealed "...PRINCIPLES FOR PERFORMANCE IMPROVEMENT 1. To measurably improve our delivery of safe, effective.... patient care. ...3. To ensure that key processes and outcome measures are tracked, communicated, assessed and acted upon when needed. ...PRIORTIES FOR IMPROVEMENT ...Patient and Associate Safety "Improve Patient Outcome Measures" High-risk care for our patients ..."

1. Medical record review on 05/23/2018 for Patient #7 revealed a 62 yo patient was admitted on 03/10/2018 following transfer from another area hospital ED for continued stabilization and treatment of "Bipolar disorder with significant mania, paranoia, and agitation." Review of the "Behavioral Health (BH) Intake Assessment" by RN #16 on 03/10/2018 at 1100 revealed "...She is having homicidal ideation... She is very anxious, manic and bizarre. She is agitated at times and paranoid. She is talking fast with disconnected thoughts and speech. ...not sleeping. ...She has racing thoughts. ..." Review of the History and Physical (H&P) dated 03/11/2018 at 1634 by MD #2 revealed "...The patient has a long history of psychiatric illness... She was sent to the emergency department because of manic and psychotic agitation. She had verbalized homicidal ideation toward the administrator... She has been manic, hyperverbal, and psychomotor restlessness here. ...difficult to redirect and becomes irritable and curses when she is. ...pressured speech...PSYCHIATRIC DIAGNOSTIC FORMULATION: ...Due to her current psychosis and mania, these symptoms place her at increased risk for harm to self or others. ..." Review of nursing progress notes revealed on 03/15/2018 at 1700, "pt. has been agitated and verbally aggressive... Pt slapped another pt this am..." Further review revealed on 03/16/2018 at 0900, "Pt was very aggressive toward other pts, hitting three of them..." and 03/30/2018 at 1635, "...Pt hit anouther pt in her face..."

Review on 05/25/2018 of the occurrence log failed to reveal an "occurrence" was entered into the "occurrence" reporting database related patient-to-patient aggression on 03/15/2018 and 03/16/2018.

Interview on 05/23/2018 and 05/25/2018 with the DPS revealed review of the "occurrence" reporting log by hospital administrative staff revealed there were no occurrence reports in the hospital tracking/monitoring system to date of any patient-to-patient aggression on 03/15/2018 and 03/16/2018 involving Patient #7. Interview revealed leadership was not aware the patient had assaulted four (4) patients during her admission until the medical record review on 05/23/2018. Interview revealed patient-to-patient aggression is considered a quality and safety incident and that an "occurrence" report should have been entered in the hospital's reporting system. Interview revealed the nursing staff failed to follow hospital policy.

Based on review of "Performance Improvement Plan" review, Performance Improvement (PI) restraint data and staff interviews, the hospital's leadership staff failed to ensure monitoring of its restraint program in the ED.

Findings included:

Review on 05/25/2018 of the hospital's policy "PERFORMANCE IMPROVEMENT PLAN" (Year 2018), revealed "GOAL The goal of the (Hospital Name) Performance Improvement Plan is to maintain an organization-wide performance improvement program based on a systemic approach to prioritizing , assessing, designing, implementing and sustaining improvements in both clinical and operational processes. ...PURPOSE OF PLAN The purpose of this plan is to provide an outline of how the organization will improve care, service outcomes, and safety for our customers in a manner consistent with our mission. ...PRINCIPLES FOR PERFORMANCE IMPROVEMENT 1. To measurably improve our delivery of safe, effective.... patient care. ...3. To ensure that key processes and outcome measures are tracked, communicated, assessed and acted upon when needed. ...PRIORTIES FOR IMPROVEMENT ...Patient and Associate Safety "Improve Patient Outcome Measures" High-risk care for our patients ..."

Review on 05/25/2018 of the hospital's "2018 Quality Indicators" revealed listed quality indicators for the ED did not include restraint use.

Review on 05/25/2018 of the hospital's aggregate "Departmental Quality Indicators Log" revealed a scorecard for "Restraint Hours" and "Restraint Hours with Violent Restraints" on the Behavioral Health unit for the third and fourth quarter of 2017 and first quarter of 2018 but did not include restraint monitoring the ED.

Interview on 05/25/2018 at 0945 with the DPS and chief nursing officer (CNO) revealed restraint use is not currently tracked and monitored cumulatively in the ED. Interview revealed, "We 've realized we have an huge opportunity for improvement in the ED" in regard to restraint use and monitoring." Interview revealed restraint use is discussed during leadership morning safety huddles on a day-to-day basis with "just-in-time discussion"; however, aggregate data is not collected for tracking and trending purposes. Interview revealed restraint use tracking and monitoring had been primarily focused on the Behavioral Health unit, without consideration of the cumulative use throughout the hospital. Interview revealed restraint use was not monitored and tracked in the ED. Further interview revealed restraint orders are not audited to ensure the presence of all the required components included in the policy, which included, "Alternatives attempted"; "Restraint Type"; "Reason for use"; "Release criteria"; and "Time Specific", that the restraint monitoring flow sheet did not indicate the time an emergency restrictive intervention was initiated or when it was discontinued and that the restraint documentation in the EMR was not complete or accurate at time. Interview revealed there was no documentation of the RN assessment every 2 hours per policy. Interview revealed, "I think we haven't seen the forest for the trees." Interview revealed that plans going forward are to develop a more robust quality program that will include monitoring, tracking, and trending restraint use in the ED. Interview revealed an educational opportunity related to chemical and manual restraint was also identified during the survey. Interview revealed prior to the state agency survey, documentation related to implementation and ongoing justification of restraint use (i.e., physician orders), monitoring, and other restraint related documentation requirements was not audited or monitored in the ED to ensure regulatory components were met.

Based on hospital policy and procedure reviews, medical record reviews and staff interviews nursing staff failed to monitor and assess 4 of 12 patients sampled (Patient #7, #8, #4, and #5 )

Findings included:

Review on 05/23/2018 of the hospital policy, "PRESSURE ULCER PROTOCOL", revised 04/21/2014, revealed "...2. Nursing shall complete skin assessment on admission and every shift. ..."

Review on 05/23/2018 of the hospital's policy, "FALL SAFETY, PREVENTION, AND DOCUMENTATION", revised 02/01/2018, revealed "...Policy 1. The nurse will assess patients upon admission and each shift for falls, initiate measures to minimize the risk of falling... Assessment 1. The nurse will evaluate patients on admission and document patient's risk for falling...Select the appropriate response for each section. The score is automatically totaled in the score box at the end of the form. ...4. The nurse will re-evaluate patient for risk for falls once each shift and document in the Morse Fall Risk Section. ...6. The nurse will implement the following interventions based on the Morse Fall Risk Score. ..."

Review on 05/24/2018 of the hospital policy, "...BEHAVIORAL HEALTH SERVICES...ASSESSMENT/DOCUMENTATION", revised 03/2013, revealed "...Procedure...1. Complete the Physical Assessments including Skin and Braden Assessment ....on admission for all units. ...3. Complete the Behavioral Health Assessments ....on admission and every 12 hour shift all units. ...7. Complete the Morse Risk Fall Assessments ....on admission and every 12 hour shift all units. 8. Complete the Pain Assessments on admission and every 12 hour shift on all units. If the patient is having pain and interventions for pain, reassess the interventions, and reassess every 4 hours as long as the patient continues to have pain. ....11. Gero-Psych Unit: Complete the Skin and Physical Assessments daily. Dayshift will complete even numbered rooms and nightshift will complete odd numbered rooms. ..."

Review on 05/24/2018 of the hospital policy, "...BEHAVIORAL HEALTH SERVICES...ASSESSMENT/DOCUMENTATION", revised 05/2018, revealed "...Procedure...1. Complete the Physical Assessments including Skin and Braden Assessment ....on admission for all units. ...3. Complete the Behavioral Health Assessments ....on admission and every 12 hour shift all units. ...7. Complete the Morse Risk Fall Assessments....on admission and every 12 hour shift all units. 8. Complete the Pain Assessments on admission and every 12 hour shift on all units. If the patient is having pain and interventions for pain, reassess the interventions every hour....9. Nursing will ensure daily hygiene/ADL's charted by CNAs for progress notes. ..."

Review on 05/24/2018 of the hospital policy, "STANDARDS OF CARE FOR PATIENTS" ...Expected Outcome: The nursing staff is responsible for providing patient care according to the following standards of care. ...Plan of Care ...Activities of Daily Living ... ...Patients/families can expect to have their physical needs met during hospitalization. 1. Assess the patient's ability to perform activities of daily living on admission and every shift and intervene as indicated. This includes: a. hygiene needs...c. elimination...2. Assess skin integrity and risk to skin impairment on admission and every shift..."

Review on 05/23/2018 of the hospital policy, "PATIENT RIGHTS AND RESPONSIBILITIES", revised 04/16/2014, revealed "... PATIENT RIGHTS: ... Respect and Dignity: The patient has the right to an environment that preserves his/her human dignity. ...The patient has the right to considerate and respectful care with recognition of his/her personal dignity..."

Review on 05/24/2018 of hospital policy, "ACTIVITIES OF DAILY LIVING - ADLS", effective 11/13/2014, revealed "... Expected Outcome: To ensure patients receive general nursing care such as bathing...if patient is unable to care for themselves and as ordered by the physician. ...Procedure: 1. The nursing staff assigned to the patient is responsible for providing and documenting care given, related to ADLs including...i.e. ...bathroom privileges. 2. Patients who are incontinent are cleaned or bathe immediately after voiding or soiling..."

Review on 05/25/2018 of the "Morse Fall Scale" (MFS) guidelines revealed it is used as a tool to "predict" a patient's likelihood of falling based on six variables:
1. History of falling; immediate or within 3 months ....Scale ...No: 0 Yes: 25 ...Scoring ...
2. Secondary diagnosis ...Scale ...No: 0 Yes: 15 ...Scoring ...
3. Ambulatory aid: Bed rest/nurse assist (Scale 0); Crutches/cane/walker (Scale 15); Furniture (Scale 30) ...
4. IV/Heparin Lock ...Scale ...No: 0 Yes: 20 ...
5. Gait/Transferring: Normal/bedrest/immobile (Scale 0); Weak (Scale 10); Impaired (Scale 20) ...
6. Mental status: Oriented to own ability (Scale 0); Forgets limitations (Scale 15) ...
Review revealed " ...Secondary diagnosis: This is scored as 15 if more than one medical diagnosis is listed on the patient's chart ...Scoring and Risk Level: The score is then tallied and recorded on the patient's chart. Risk level and recommended actions (e.g. no interventions needed; standard fall prevention interventions, high risk prevention interventions) are then indentified. ...Sample Risk Level ...Risk Level: No Risk 0-24 Action: Good Basic Nursing Care; Low Risk 25-50 Action: Implement Standard Fall Prevention Interventions; High Risk > 51 Action: Implement High Risk Fall Prevention Interventions."

1. Medical record review on 05/23/2018 for Patient #7 revealed a 62-year-old (yo) was admitted to Unit A on 03/10/2018 with a chief complaint of "Bipolar disorder with significant mania, paranoia, and agitation." Review revealed a history of falls; bilateral lower extremity pitting edema, "Notable for 3+ pitting and ankle edema extending midway up the pretibial area. Her feet and ankles are tender. Feet are mildly erythematous ..." per the History and Physical (H&P) by MD #2 on 03/11/2018 at 1017.
Review of nursing assessments revealed:
- 03/17/2018: 1109 MFS score: 40; no documented 7p-7a fall risk assessment
- 03/18/2018: 0815 and 2002 MFS score: 15 ("Presence of secondary diagnosis" not marked)
- 03/19/2018: 2115 MFS score: 15 ("Presence of secondary diagnosis" not marked)
- 03/20/2018: 0936 MRS score: 15 ("Presence of secondary diagnosis" not marked); no documented 7p-7a fall risk assessment
- 03/21/2018: 1100 MFS score: 40 (all variables of the assessment tool evaluated and included in the total score)
- 03/27/2018: no documented 7a-7p fall risk assessment
- 04/03/2018: 0800 presence of "IV or IV access" and "Mental Status" blank; no documented fall risk score
- 04/04/2018: no documented 7a-7p fall risk assessment
Review revealed the box for "Presence of secondary diagnosis" was not consistently checked as well as other variables of the assessment tool that resulted in continued changes in the patient's overall fall risk assessment. Further review of nursing assessments failed to reveal documented skin assessments on:
- 03/13/2018 - 03/15/2018
- 03/17/2018
- 03/20/2018 - 03/22/2018
- 03/31/2018
Review of the vital signs flow sheet failed to reveal documented vital signs:
- 03/30/2018 and 03/31/2018 during the 7a-7p shift
- 04/04/2018: Vital signs taken at 0900 and not repeated again until 04/05/2018 at 0500.
Review revealed nursing staff failed to obtain and evaluate the patient's vital signs per the expected protocol.

Interview on 05/23/2018 at 1515 with RN #3 revealed she was the primary nurse assigned to Patient #7 on 03/27/2018 on the 7a-7p shift. During review of the fall risk and skin assessment documentation, interview revealed RN #3 indicated she was unable to verify that an assessment had been performed during her shift per policy. "It doesn't look like it ....I don't see any (documentation)." Interview revealed she remembered the patient but was unable to recall what her assessment of the patient's fall risk status and skin were on 03/27/2018. The nurse shared that fall assessments were part of the daily assessment; however, she could not confirm one had been done. Interview confirmed a completed fall risk assessment was not documented on 03/27/2018 during the 7a-7p shift and that the nurse could not verify one was performed per policy.

Interview on 05/25/2018 at 1300 with CNA #1 revealed she was assigned vital signs on the staff assignment sheet on 03/31/2018 during the 7a-7p shift. Interview revealed, "He could have been resting and probably just got busy and forgot to go back." Interview revealed she was unable to verify that vital signs were obtained on 03/31/2018.

Interview on 05/25/2018 at 1330 with the clinical manager of Behavioral Health Services revealed nursing staff are expected to perform a complete assessment on admission and every 12 hours. Interview revealed it was her (CM) expectation that a complete assessment would include a skin assessment and accurate fall risk assessment. Interview revealed nursing staff are expected to take vital signs every shift between 0500-0600 on the 7p-7a shift and 1700-1800 on the 7a-7p shift. Interview revealed nursing staff failed to complete nursing assessments and vital signs per policy.

2. Medical record review on 05/24/2018 for Patient #8 revealed a 32 yo was admitted on 04/16/2018 "following a life-threatening MVA (motor vehicle accident) while drinking". Review revealed the patient was involved in a MVA two week prior to admission and had injury to her right foot, left knee, and right upper torso. Review revealed a diagnosis of attention deficit/hyperactivity disorder (ADHD) vs. bipolar vs. anxiety, alcohol use disorder, substance use disorder, and seizures. Review of nursing assessments revealed:
- 04/16/2018: 1000 MFS score: 35 ("Presence of secondary diagnosis" not marked)
- 04/17/2018: 0900 MFS score not documented.
- 04/17/2018: 2111 MFS score: 35 ("Presence of secondary diagnosis" not marked)
- 04/18/2018: 1034 MFS score: 50 (15 point difference with all variables of the assessment tool evaluated and included in the total score).
Review of skin assessments revealed:
- 04/17/2018: 0900 Integumentary documentation incomplete ("Skin Temperature"; Skin Turgor/Characteristics"; "Mucous Membrane Color"; "Mucous Membranes"; and "Integumentary Note" blank). Review revealed nursing staff failed to complete nursing assessments per policy.

Interview on 05/25/2018 at 1315 with RN #21 revealed he was the primary nurse assigned to Patient #8 on 04/17/2018 during the 7a-7p shift. Interview revealed nursing staff are required to complete a skin assessment "once per shift" (every 12 hours). Interview reveled he could not recall whether an assessment was performed on 04/17/2018 at 0900 during his morning assessment. Interview revealed the patient "may have refused. There should be one on there (in the medical record). It may not be in my notes and I may not have specifically documented her refusal in a note." Interview revealed RN #21 not able to recall completing a skin assessment or locate documentation of one on 04/17/2018.

Interview on 05/25/2018 at 1330 with the clinical manager of Behavioral Health Services revealed nursing staff are expected to perform a complete assessment on admission and every 12 hours. Interview revealed it was her (CM) expectation that a complete assessment would include a skin assessment and accurate fall risk assessment. Interview revealed nursing staff are expected to take vital signs every shift between 0500-0600 on the 7p-7a shift and 1700-1800 on the 7a-7p shift. Interview revealed nursing staff failed to complete nursing assessments and vital signs per policy.

3. Medical record review on 05/25/2018 for Patient #4 revealed an 87 yo was admitted to Unit A on 05/16/2018 at 1348 with a diagnosis of dementia with behavioral disturbances and a secondary diagnosis of chronic and acute pain in the left leg related to "Total right knee arthroplasty" and "Advanced multilevel lumbar spondylosis." Review revealed a medical history of head injury from a fall in 2013; near syncope, dizziness, and difficulty breathing. Review revealed Review of the nursing assessments revealed:
- 05/16/2018 at 1400: Morse Fall Scale (MFS) score: 60 ("Presence of Secondary Diagnosis" documented as "No")
- 05/16/2018 at 1800: MFS score: 50 ("History of Falling" documented as "No" and "Presence of Secondary Diagnosis" assessed as "No")
- 05/23/2018 at 0800: MFS score not documented. "History of Falling" documented as "Unknown" and "Presence of Secondary Diagnosis" documented as "No". Review revealed 4 of 6 variables of the fall assessment tool were not documented. Further review of nursing assessments failed to reveal a documented skin assessment on 05/22/2018 during the 7p-7a shift. Review of the vital signs flow sheet failed to reveal documentation of vital signs on 05/18/2018 during the 7p-7a shift. Review revealed nursing staff failed to complete nursing assessments and vital signs per policy.

Interview on 05/23/2018 at 1515 with RN #2 revealed she was the patient's primary care nurse 7a-7p on 05/16/2018. Interview revealed RN #2 could not recall why a complete fall risk assessment was not documented and suggested she may have been called away to care for another patient and forgot to complete documentation of her assessment. Interview revealed RN #2 was not able to recall what her assessment of the patient's fall risk status on 05/16/2018. Interview confirmed a completed fall risk assessment was not documented on 05/22/2018 at 0800 per policy.

Telephone interview on 05/25/2018 at 1335 with RN #4 revealed he was the primary nurse assigned to Patient #4 on 05/18/2018 - 05/22/2018 during the 7p-7a shift. Following review of fall risk assessment findings during the medical record review revealed "It was an error on my part for checking that box ("Presence of Secondary Diagnosis")." Review of the vital signs findings revealed the CNA (certified nursing assistant) staff are "usually able to get them" (vital signs) and when they are unable to obtain, "CNAs bring it to the nurse's attention." Interview revealed RN #4 could not recall circumstances that may have prevented staff from obtaining vital signs on 05/18/2018 and that the nurse was not aware they were missing. Further interview revealed vital signs should include the BP, Temperature, and Pulse. Interview revealed RN #4 could not verify that a skin assessment was performed on 05/22/2018.

Interview on 05/25/2018 at 1330 with the clinical manager of Behavioral Health Services revealed nursing staff are expected to perform a complete assessment on admission and every 12 hours. Interview revealed it was her (CM) expectation that a complete assessment would include a skin assessment and accurate fall risk assessment. Interview revealed nursing staff are expected to take vital signs every shift between 0500-0600 on the 7p-7a shift and 1700-1800 on the 7a-7p shift. Interview revealed nursing staff failed to complete nursing assessments and vital signs per policy.

4. Medical record on 05/25/2018 for Patient #5 revealed an 88 yo presented to the ED on 05/18/2018 at 1143 via ambulance following aggressive behaviors toward staff at a skilled nursing facility (SNF) and was admitted to Unit A on 05/18/2018 at 2156. Review of urinalysis results revealed the patient had a UTI and was started on Keflex with a urine culture pending. Review revealed diagnoses included confusion, dementia, aggression, agitation, COPD, heart disease, and history of alcohol use. Review of the Behavioral Health H&P on 05/19/2018 at 0720 revealed, "...Treatment Plan Psychiatric 5/19 monitor patients behavior prior to arrival patient had multiple injections including Klonopin Depakote Ativan and Geodon Start patient on medication Review of nursing assessments revealed:
- 05/18/2018 at 2200: MFS score: 0 (Note: pt received Klonopin Depakote Ativan and Geodon prior to admission to Unit A. "Presence of Secondary Diagnosis" not marked)
- 05/19/2018: 7a-7p no documented fall risk assessment; 1900: MFS score: 0 ("Presence of Secondary Diagnosis" not marked)
- 05/20/2018 at 1000: MFS score: 40; 1900 score: 0 ("Presence of Secondary Diagnosis" not marked)
- 05/21/2018 at 0900 MFS score: 25; 1900 score: 0 ("Presence of Secondary Diagnosis" not marked)
- 05/22/2018 at 1000: MFS score: 25; 1900 MFS score 0 ("Presence of Secondary Diagnosis" not marked)
Review revealed the box for "Presence of secondary diagnosis" was not consistently checked and resulted in continued changes in the patient's overall fall risk assessment. Further review of nursing assessments failed to reveal a documented skin assessment on 05/21/2018 during the 7a-7p shift. Review of the vital sign flow sheet revealed:
- 05/18/2018: 0500-0600 no documented vital signs
- 05/19/2018: 0600 Respirations 18 with no documented BP; Pulse; or Temp.
- 05/21/2018: 0500-0600 no documented vital signs
Review of nursing skin assessments failed to reveal a documented skin assessment on 05/21/2018 during the 7a-7p shift per policy. Review revealed nursing staff failed to complete nursing assessments and vital signs per policy.

Telephone interview on 05/25/2018 at 1335 with RN #4 revealed he was the primary nurse assigned to Patient #5 on 05/18/2018 - 05/22/2018 during the 7p-7a shift. Following review of fall risk assessment and vital sign findings during the medical record review revealed "It was an error on my part for checking that box ("Presence of Secondary Diagnosis")." Interview revealed the CNA (certified nursing assistant) staff are "usually able to get them" (vital signs) and when they are unable to obtain, "CNAs bring it to the nurse's attention." Interview revealed RN #4 could not recall circumstances that may have prevented staff from obtaining vital signs on 05/18/2018 or 05/21/2018 and that the nurse was not aware they were missing. Further interview revealed vital signs should include the BP, Temperature, and Pulse.

Interview on 05/25/2018 at 1330 with the clinical manager (CM) of Behavioral Health Services revealed nursing staff are expected to perform a complete assessment on admission and every 12 hours. Interview revealed the nurse responsible for the care of Patient #5 on 05/21/2018 during the 7a-7p shift was not available for interview, but it was her (CM) expectation that a complete assessment would include a skin assessment and accurate fall risk assessment. Interview revealed nursing staff are expected to take vital signs every shift between 0500-0600 on the 7p-7a shift and 1700-1800 on the 7a-7p shift. Interview revealed nursing staff failed to complete nursing assessments and vital signs per policy.

Based on hospital policy and procedure reviews, medical record reviews and staff interviews nursing staff failed to assess and monitor patients for the effectiveness of medications for 6 of 12 patients (Patient #7, #8, #10, #15, #17, and #18) and failed to follow a sliding scale insulin physician order and to obtain a second nurse verification for a high-risk medication per policy (Patient #9).

Findings included:

Review on 05/23/2018 of the hospital's policy, "PAIN IDENTIFICATION AND MANAGEMENT OF", revised 03/21/2018 revealed, " ...Frequency of Pain Assessment ...pain should be assessed: 1. upon admission 2. with each VS assessment ...4. Following pharmacological interventions and/or non-pharmacological inventions for pain ..."

Review on 05/23/2018 of the hospital's policy, "PATIENT RIGHTS AND RESPONSIBILTIES", revised 04/16/2014, revealed "...Pain The patient has the right to have pain treated as effectively as possible. ..."

Review on 05/24/2018 of the Hospital's Policy, "GENERAL MEDICATION ADMINISTRATION", revised 03/26/2018 revealed, "...28. Second nurse verification of medication and dosage with another licensed nurse is required for: a. insulin ...30. Response effect(s) to PO/IV/PRN medications will be charted within one hour on e-Mar. ..."

Review on 05/24/2018 of the hospital policy, "STANDARDS OF CARE FOR PATIENTS" ...Expected Outcome: The nursing staff is responsible for providing patient care according to the following standards of care. ...Plan of Care ...Activities of Daily Living ...3. Assess patient's comfort/pain per (Hospital A) policy and intervene as ordered/indicated. ...

Review on 05/24/2018 of the hospital policy, "CONTENT AND REQUIRED FORMAT OF THE PERMANENT HOSPITAL MEDICAL RECORD", revised 02/26/2018, revealed "...Completed Medical Records Shall Contain: The permanent medical record contains patient specific information. as appropriate, to the care, treatment, and services provided. Each medical record shall contain at least the following... 2. Clinical Information: ...Findings of assessments and reassessments... "

Review on 05/25/2018 of the hospital policy, "ELEMENTS OF THE HEALTH ASSESSMENT", revised 03/26/2015, revealed "...Elements to be included in the Health Assessment Report ... 5. Review of systems - physical examination of the patient; and, 6. Summary statement including problems and focus of treatment. ..."

A. The hospital nursing staff failed to assess and monitor patients for the effectiveness of medications for 8 of 12 patients (Patient #5, #7, #8, #10, #15, #17, and #18).

1. Closed medical record review on 05/23/2018 for Patient #7 revealed a 62 yo was admitted on 03/10/2018 with a chief complaint of "Bipolar disorder with significant mania, paranoia, and agitation." Review of the MAR revealed Tylenol 650 mg by mouth was administered for pain:
- 03/12/2018 at 0933 for foot pain reported as 10 on a scale of 1 to 10
- 03/13/2018 at 0138 for throat pain reported as 3 on a scale of 1 to 10
- 03/14/2018 at 0046 for foot pain reported as 10 on a scale of 1 to 10
- 03/19/2018 at 2106 for foot pain reported as 10 on a scale of 1 to 10
Review revealed with no documented reassessment of the effectiveness of pharmacological intervention on 03/12/2018 at 0933 or 03/13/2018 at 0138 per policy. Review revealed "See FLACC" (Face, Legs, Activity, Cry, Consolability scale measurement used to assess pain for individuals that are unable to communicate their pain scored in a range of 0-10 with 0 representing no pain) documented for 03/14/2018 at 0046 and 03/19/2018 at 2106 with no score documented.

Interview on 05/25/2018 at 1335 with RN #4 revealed he was the 7pm to 7am primary nurse for Patient #7 on 03/13/2018, 03/14/2018, and 03/19/2018. Interview revealed failure to document reassessment of the effectiveness of the Tylenol on 03/12/2018 and 03/13/2018 and the FLACC score was an oversight and should have been documented according to hospital policy.

Interview on 05/25/2018 at 1330 with the nurse manager of Behavioral Health Services revealed nursing staff are expected to reassess the effectiveness of pharmacological interventions within one (1) hour of administration. Interview revealed nursing staff failed to reassess the patient's pain per policy.

2. Closed medical record review on 05/24/2018 for Patient #8 revealed a 32 yo was admitted on 04/16/2018 "following a life-threatening MVA (motor vehicle accident) while drinking". Review revealed the patient was involved in a MVA two week prior to admission and had injury to her right foot, left knee, and right upper torso. Review revealed a diagnosis of attention deficit/hyperactivity disorder (ADHD) vs. bipolar vs. anxiety, alcohol use disorder, substance use disorder, and seizures. Review of the MAR revealed RN #17 administered:
-Tylenol 650 mg by mouth prn pain at 04/19/2018 at 0425 and 04/20/2018 at 1305;
- Ibuprophen 400 mg by mouth prn pain at 04/19/2018 at 0425 and 0933 and 04/20/2018 at 1305; and
Tramadol 100 mg by mouth prn pain at 04/19/2018 at 1430, 04/20/2018 at 1025, and 04/21/2018 at 1003 with no documented reassessment of the effectiveness of pharmacological interventions per policy.

Interview on 05/25/2018 at 1330 with the nurse manager of Behavioral Health Services revealed nursing staff are expected to reassess the effectiveness of pharmacological interventions within one (1) hour of administration. Interview revealed nursing staff failed to reassess the patient's pain per policy. Interview revealed RN #17 was a travel nurse and was no longer an employee.



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4. Open medical record review on 05/24/2018 of Patient #10 revealed, an 82 year old female was admitted on 05/12/2018 - 05/22/2018 with chief complaint of nausea and vomiting, which required surgery on 05/16/2018 for a partial colectomy. During the hospitalization which required surgery, pain management would be clinically prioritized as part of the standard care of a surgical patient. However, review of the MAR revealed pain management was not followed up after the patient received medication. The medical record revealed the following pain assessment and management documentations:

- On 05/13/2018 at 1900 the patient reported pain of 7/10 with the physician order initiated and administration at 2300 of Percocet.
- On 05/14/2018 at 0300: Reassessment of pain documented as "patient appears to be sleeping" (failed to assess effectiveness of pain medication)
- On 05/14/2018 at 1928 revealed the patient reported pain of 8/10 with the administration of Percocet.
- On 04/14/2018 at 2300: Reassessment of pain documented as "Yes", pain medications (failed to assess effectiveness of pain medication)
- On 05/14/2018 at 2339 revealed the patient reported pain of 7/10 with the administration of Percocet.
- On 05/15/2018 at 0300: Reassessment of pain documented as 3/10 (failed to assess effectiveness of pain medication)
- On 05/15/2018 at 1502 revealed the patient reported pain of 4/10 with the administration of Percocet (failed to assess effectiveness of pain medication)

Interview on 05/25/2018 at 0945 with RN #23 revealed, RN #23 is the nurse who gave 1 Percocet tablet on 05/13/2018 at 2300 with a pain reassessment documented at 0300 as "proxy, patient appears to be sleeping". On 05/14/2018 at 1928, 1 Percocet tablet was given with a pain reassessment at 2300 documented as "yes pain medications" with the administration of medication documented as 1 Percocet given at 2339. Interview confirmed, after the administration of pain medication, nursing should perform a reassessment of pain within 1 hour of the administration of medication. Interview revealed nursing failed to perform a pain reassessment as per policy.

5. Closed medical record review on 05/23/2018 of Patient #15 revealed, a 79 year old male admitted on 03/01/2018 - 03/07/2018 with a chief complaint of abdominal pain and nausea resulting in an admitting diagnosis of acute pancreatitis. The medical record revealed as follows:
- On 03/01/2018 at 1922 Patient was administered 4 mg (milligrams) IV (intra-venous) Morphine for pain of 8/10 without documentation of follow up reassessment of pain until 2131 (1 hour and 40 minutes later)
- On 03/01/2018 at 2230 Patient was administered 2 mg IV Morphine for pain 8/10 without documentation of follow up reassessment. The medical record reveals the next documentation of pain reassessment at 03/02/2018 at 0554 (greater than 6 hours later)
- On 03/02/2018 at 1943 Patient was administered 4 mg IV Morphine for a pain of 7/10 and the pain reassessment was performed at 2300 (2 hours and 15 minutes later)
- On 03/04/2018 at 0800 Patient was administered 4 mg IV Morphine for pain score of 6/10. The pain reassessment was performed at 1100 was documented as a 6/10 (2 hours later without notification of any further intervention or notification to the physician of no relief of pain, score still documented as 6/10)

The medical record revealed RN #23 administered 4 mg IV Morphine on 03/04/2018 at 1954 to Patient #15 for a pain score of 8/10 and the reassessment of pain was performed at 2300 (3 hours later) documented as proxy pt. appears to be sleep.

Interview on 05/25/2018 at 0945 with RN #23 revealed, the nursing practice and policy requires follow up reassessment within 1 hour after the administration of as needed pain medication (PRN). The interview revealed the pain reassessment was not followed as per policy.

Interview on 05/23/2018 with RN #14 revealed, the record does not reflect the documentation of follow up pain reassessments after the administration of PRN pain medication for Patient #15 on at least 4 occasions. The interview revealed the pain reassessment was not followed as per policy.

6. Open medical record review on 05/24/2018 of Patient #17 revealed, a 65 year old female admitted 05/21/2018 for Surgical Reversal of Colostomy. The medical record revealed a physician order on 05/21/2018 at 2131 for 2mg (milligrams) Morphine IV push which RN #23 documented the reassessment at 2300 (1 hour and 30 minutes later) and on 05/22/2018 at 0512 the medication was administered with the next assessment of pain at 0700 (1 hour and 48 minutes later) without follow up reassessment in the timeframe as per policy. On 05/23/2018 at 1253 the medical record revealed 400 mg Ibuprofen po (by mouth) was administered, with the reassessment of pain done at 1400 (2 hours and 7 minutes later). The record review revealed the pain reassessments were not performed as per policy.

Interview on 05/25/2018 at 0945 with RN #23 revealed, the nursing practice and policy requires follow up reassessment within 1 hour after the administration of as needed pain medication. "Typically I would have documented at 0357 IV Morphine given for pain of 7/10 as the pain score and then document a follow up score as whatever they (the patient would) say. If the patient is asleep I would document proxy patient asleep without a true score. ..." The interview revealed the reassessment of pain was not performed as per policy.

Interview on 05/25/2018 with RN #14 revealed, the record does not reflect the documentation of follow up reassessment after the administration of pain medication for Patient #23. The facility policy was not followed for reassessment of pain after the administration of medication.

7. Closed medical record review on 05/24/2018 of Patient #18 revealed, a 48 year old male admitted on 05/21/2018 - 05/22/2018 for Acute relapsing Multiple Sclerosis (a disease in which the immune system eats away at the protective coverings of nerves causing muscle spasms). The medical record revealed a physician order of 4 mg Morphine IV every 4 hours for severe pain PRN (as needed) and 2 Percocet tablets po (by mouth) every 6 hours PRN moderate pain. The medical record revealed as follows:
- 05/22/2018 at 0659: 4 mg IV Morphine was administered for pain of 6/10 with follow up pain assessment performed at 0919 (2 hours and 20 minutes later).
- 05/22/2018 at 1100: 4 mg IV Morphine was administered for pain 5/10 and the record does not reflect a follow up reassessment of pain after the administration of as needed pain medication (the next documentation of pain assessment is at 1400, (3 hours later).

Interview on 05/24/2018 with RN #14 revealed the pain reassessment should have been performed within 30 minutes of intravenous pain medication administration. The record does not reveal a pain reassessment was performed as policy.

Interview on 05/25/2018 at 0925 with RN #24 revealed that on 05/22/2018 at 0659 4 mg IV Morphine was given to Patient #18 and communication was made to day shift RN to reassess for the pain medication administration. RN #24 revealed that the day shift nurse was informed of the medication administration in RN to RN hand off communications. The computerized documentation is set up to display red boxes to remind the nurse the reassessment is needed but is outside of the timeframe. A blue color box would remind the nurse to reassess and document the results of pain relief if performed within acceptable timeframe. The record does not reveal a pain reassessment was performed as policy.

B. The hospital nursing failed to follow a sliding scale insulin physician order and to obtain a second nurse verification per policy, resulting in an insulin medication error for 1of 2 patients receiving insulin (Patient #9).

Open medical record review on 05/24/2018 of Patient #9 revealed, a 73 year old female admitted on 05/22/2018 - 05/24/2018 for COPD (chronic obstructive pulmonary disease, a disorder of a group of lung diseases that block airflow and make it difficult to breath) Exacerbation. Her history included diabetes with oral medications as the treatment. The record revealed, "No" on the MAR (electronic medication administration record) for the second nurse verification and the glucose result appeared in the record as 243 which would require 3 units to be given to Patient #9. The documentation revealed 5 units was given at 0744 on 05/23/2018. The record revealed, "No" on the MAR (electronic medication administration record) for the second nurse verification and the glucose result appeared in the record as 207 at 1954 which would require 2 units to be given. However 1 unit was given and documented. During her hospitalization orders were for Correctional Dose Insulin Medium Dose scale as follows:

Interview on 05/25/2018 at 1045 with RN #12 revealed, the RN is required to obtain two nurse verification of the correct dosage of Insulin for the corresponding glucose result. Interview revealed there was no evidence of a second nurse verification of correct dosage of Insulin administration.

Interview on 05/25/2018 at 1100 with RN #14 Clinical Educator revealed, the record reflects on 05/23/2018 at 0744 for a glucose resulted as 243, the wrong dose of Insulin (5 units) was given to Patient #9 and there was no documentation of a second nurse verification.