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Based on document review and interview, nursing services failed to notify the provider of medications held, failed to document intravenous medications administered, failed to ensure a nutritional consultation was completed, failed to notate 6 of 9 provider orders, and failed to ensure patient medication reconciliation was completed in 1 of 10 patients (Patient 6) medical records reviewed.

Findings include:

1. Facility policy titled, Standardized Medication Administration, PolicyStat ID: 12197198, last approved 08/2022, indicated under General Knowledge, B. All medications administered will be recorded in the patient's Medication Administration Record (MAR) including the initials of the person administering the medication.

2, Facility policy titled Medication Reconciliation (Admission and Discharge Medications), PolicyStat ID 12197197, last approved 01/2025, indicated under Medication Reconciliation Procedure: B. The provider must order each drug, dosage, etc. by written or verbal order. Those medications, which match these orders, are considered to be reconciled and a check should be placed in the "(admit) Continue" box.

3. Facility policy titled Hypertensive Medication and Hold Parameters, PolicyStat ID 65480035, last approved 01/2025, indicated under Procedure: 2. Hold parameters for Hypertensive Medications: Medication is to be held if: SBP equal to or less than 100 mmHg and/or HR less than 60 bpm. Medication must be withheld if one or both conditions apply. Provider Notification: Notify the provider immediately of any abnormal findings. Documentation must include: Provider notification, Orders received (e.g. "Give medication", "Hold medication", "Recheck vitals"), any follow-up actions taken.

4. Review of Patient 6's medical record indicated the following:
a. The patient was admitted on 09/23/2025 for agitation, confusion, refusing to take medications and recent cognitive changes in the past 48 hours.
b. On 09/25/2025, provider ordered a nutritional consultation; medical record lacked documentation of a nutritional consultation; provider orders lacked date and time of nursing notation.
c. On 09/27/2025, the medical record indicated the provider ordered intravenous (IV) fluids for dehydration; Nursing note at 12:30 p.m. indicated IV placed, patient tolerated well. Medication administration record lacked documentation of the IV fluids that were administered, start time of IV fluid administration, and end time when administration infusion was complete. Nursing note at 6:30 p.m. indicated patient refused to dinner, patient weak but alert, provider notified, and order received to transfer patient for further evaluation and treatment. Patient transferred at 6:50 p.m. to Facility #2 (Acute Care Facility). Three provider orders lacked date and time of nursing notation, one provider order lacked documentation of date, time, and signature of nursing notation.
d. On 09/28/2025, the medical record indicated patient returned from Facility #2 and the patient was treated for dehydration. The medication administration record indicated on 09/28/2025, ordered Norvasc 10 mg and Toprol-XL 50 mg were held; did not meet facility's policy parameters to hold for a systolic blood pressure equal to or less than 100 and/or heart rate less than 60. Medical record indicated patient's blood pressure was 118/74 and pulse was 87. Medical record lacked documentation of provider notification.
e. On 09/29/2025. the medication administration record indicated on 09/29/2025, ordered Norvasc 10 mg and Toprol-XL 50 mg were held and did not meet facility's policy parameters of systolic blood pressure equal to or less than 100 and/or heart rate less than 60. Medical record indicated patient's blood pressure was 109/73 and pulse was 107. Medical record lacked documentation of provider notification. Medical record indicated the provider ordered intravenous fluids for lethargy; nursing note at 8:50 a.m. indicated IV started successfully and running patent. Medication administration record lacked documentation of the IV fluids that were administered, start time of IV fluid administration, and end time when administration infusion was complete. Provider order lacked documentation of date, time, and signature of nursing notation. Nursing note at 10:55 a.m. indicated patient became more lethargic, order received to transfer patient for further evaluation and treatment. Patient was transferred at 11:07 a.m. to Facility #2. Nursing note at 2:00 p.m. Facility #2 indicated patient was admitted with a diagnosis of stroke. Patient did not return to Facility #1 (Psychiatric Care Facility).

5. Interview with A3 (Director of Quality and Compliance) and A4 (Director of Nursing) 11/03/2025 at approximately 3:10 p.m. confirmed the following:
a. Patient 6's medication administration record indicated on 09/28/2025 and 09/29/2025 that the patient's ordered Norvasc 10 mg PO and Toprol-XL 50 mg PO were held; and patient's vital signs did not meet the parameters to hold medication and medical record lacked documentation of provider notification.
b. Patient was administered intravenous fluids on 09/27/2025 and 09/29/2025. Medication administration record lacked documentation of intravenous fluid administration.
c. Medication Reconciliation Form lacked documentation of which home medications were ordered and provider signature.
d. The following dates for provider orders lacked documentation of complete nursing notation: 09/25/2025, all provider orders on 09/27/2025, and 09/29/2025.