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Based on document review, interview and observation, the facility failed to ensure the safety of patients in 1 (unit 4) of 5 units toured.

Findings include:

1. Policy/procedure, Patient Rights, Policy: RR 14.01, revised/reviewed 1/31/19, indicated on page 2: "Patients have the right to be served in a clean, safe and secure environment.

2. On 1/13/20 at approximately 1630 hours, the facility was toured accompanied by staff N7 (Director of Risk). Upon tour of unoccupied room 409 on unit 4 a handwritten sign was observed on the door stating 'bathroom'. Upon entering unoccupied room 409, dirty towels and trash were observed in the bathroom as well as two beds without linens each containing call lights with cords hanging from the lower part of the bedframe.

3. On 1/13/19 at approximately 1630 hours, staff N8 (Behavioral Health Attendant [BHA]) was interviewed and confirmed the bathroom in room 409 was being used by patients on the unit. Staff N8 acknowledged a call light was hanging from each of the two bedframes in room 409. Staff N7 (Director of Risk) confirmed the call lights were a potential patient safety hazard.

Based on document review and interview the facility failed to ensure staff followed policies/procedures related to patient transfers, incidents and belongings in 3 (patient 1, 2 and 3) of 10 medical records (MR) reviewed as well as failed to follow policy/procedure for telephone/verbal orders and safe administration of medications in 1 (patient 2) of 10 medical records (MR) reviewed:

Findings include:

1. Patient 1's MR: Review of form entitled 'Patient Belongings' dated 12/6/19 at 2020 hours was signed per patient and staff member acknowledging an accurate listing of patient 1's belongings including Medications brought to facility however the Medications section of the form was found to be blank. Review of Patient Belongings form dated 12/12/19 indicated patient 1 acknowledged receiving all belongings as listed on the form at discharge however the form was blank despite patient's signature acknowledging receipt of items.

2. Patient 2's MR: Review of Physician Medication Orders dated 12/15/19 at 1420 hours per medical staff D3 (Physician) indicated: "hydrocodone/acetaminophen 7.5 mg/325 mg oral four times daily; Clonidine taper orders (hold for systolic blood pressure less than 120) day 1 (12/15/19) - 0.2 mg oral four times daily, day 2 (12/16/19) - 0.2 mg oral three times per day". Review of the Physician Medication Order dated 12/15/19 at 1420 hours indicated staff N3 (Registered Nurse [RN]) accepted the order but failed to document the physician validated it by writing 'Confirmed' and/or 'Verified'.
Review of Medication Administration Record (MAR) dated 12/16/19 at 0900 hours indicated staff N5 (RN) administered the following medications to patient 2: "hydrocodone/acetaminophen 7.5/325 mg oral; Clonidine 0.2 mg oral".
Review of patient 2's MR lacked documentation that staff N5 checked patient 2's blood pressure prior to administering Clonidine.
Review of MAR dated 12/15/19 lacked documentation that Norco was to be administered "as needed for pain" and Clonidine was to be held for systolic blood pressure less than 120.
Review of Nursing Progress Note dated 12/16/19 at 0905 hours per staff N4 (RN) indicated: "...Blood pressure 90/60, respirations 18, pulse 110".
Review of Nursing Progress Note dated 12/16/19 at 1030 hours indicated: "Patient blood pressure decreased, informed medical, psych and supervisor while continuously monitoring patient. Completed neuro assessment. Patient pinpoint eyes, multiple attempts to stimulate response, patient stated feeling weak. Per medical staff D1 have patient lie down and elevate feet, call ED and send patient to ED for evaluation".

3. Review of patient 2's MR lacked documentation related to the transfer of the patient to an outside facility for medical emergency, specifically, a completed Disposition form, Transfer forms and details related to the notification of the accepting facility.

4. Review of patient 3's MR lacked nursing documentation of the patient's continued seizure activity between the hours of 1400, when the first seizure occurred, until 1600 hours when the patient was transferred to an outside facility.

5. Review of patient 3's MR lacked documentation related to the transfer of the patient to an outside facility, specifically, a completed Disposition form, Transfer forms and details related to the notification of the accepting facility.

6. Review of Incident Reports dated 12/1/19 through 1/13/20 lacked documentation of events related to the accidental overdose and transfer of patient 2 as well as the transfer of patient 3 for medical evaluation.

7. Policy/procedure, Admission, Disposition and Transfer of Emergency Cases, Policy PC 8.116, revised/reviewed 1/31/19 indicated on page 2: "...Staff will complete the Disposition form. In the event the patient must be transported/transferred by EMS, staff will complete transfer forms...staff will notify the accepting facility of the decision to transfer the patient and give report".

8. Policy/procedure, Incident Reporting, Policy: RM 15.03, revised/reviewed 1/31/19 indicated: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident must complete an Incident Report as soon as possible and no later than 4 hours after the incident has occurred and before the end of the shift the person(s) is working (whichever comes first). The Incident Reporting (IR) narrative section must clarify all antecedent details, behaviors and response to the incident so that concerned parties can understand what happened. An incident Report should be completed for any incident out of the ordinary including, but not limited to: 2.5 An event occurs which, by standards, appears unexpected and/or unintended (i.e., medication error, medical emergency)".

9. Policy/procedure, Medication Management, Policy: PHR-118, revised/reviewed 02/19 indicated: "Purpose: to contribute to the process of reconciliation of all medications across the continuum of care...The medication order will be reviewed by the pharmacist".

10. Policy/procedure, Telephone and Verbal Orders, Policy CTS-270, revised/reviewed 1/31/19 indicated on page 2: "After physician validates the order as correct the nurse taking the order will indicate "Confirmed" or "Verified" in the margin under date and time of transcription".

11. On 1/13/20 at approximately 1500 hours, staff N6 (Director of Nursing) was interviewed and confirmed patient 2's MR indicated the patient was administered a combination of medication that resulted in accidental overdose. Staff N6 confirmed the patient was transferred to F3 for treatment. Staff N6 confirmed the medication, Clonidine, was not transcribed properly from the physician's order to the MAR. Staff N6 confirmed the transcription of the Clonidine order to the MAR failed to include the statement "hold if systolic blood pressure less than 120". Staff N6 confirmed the patient's systolic blood pressure was not noted per staff N5 (RN) at time of medication administration. Staff N6 confirmed patient 2's Physician Order for Norco was not written to be administered "as needed for pain" and was written to be administered four times daily. Staff N6 confirmed the Norco was written on the MAR to be administered four time daily as ordered per the physician. Staff N6 confirmed the Physician Medication Order dated 12/15/19 at 1420 hours indicated staff N3 (RN) accepted the order but failed to document the physician validated it by writing "Confirmed" and/or "Verified". Staff N6 confirmed staff failed to follow policy/procedure for documenting patient 2 and 3's transfer for medical emergency. Staff N6 confirmed the incidents related to patient 2 and 3 were not documented per facility policy/procedure for Incident Reporting. Staff N6 confirmed patient 1's MR lacked documentation of the Medication section of the Patient Belongings form dated 12/6/19. Staff N6 confirmed patient 1's MR lacked documentation the patient's belongings were returned to him/her upon discharge on 12/16/19.

12. On 1/13/20 at approximately 1530 hours medical staff D1 (Physician Assistant [PA]) was interviewed and confirmed patient 2's MR indicated the patient was transferred to an outside facility on 12/16/19 for treatment of an accidental overdose.