HospitalInspections.org

Based on record review and interview, the facility failed to

A. ensure patient care was provided by the order of a physician for 1 of 15 (#2) patients. The facility failed to ensure 1 of 15 (#2) patients were assessed and monitored for safety while hospitalized in the facility. The facility also failed to follow their own policy to maintain safe management of aggressive or destructive behavior which led to patient #2 being removed by police and charged with terroristic threats. The facility failed to ensure the emotional safety of 1 of 15 (#1) patients by not facilitating a room change requested by the patient.
Refer to A-144

B. provide medication teaching and obtain informed consent for a neuroleptic psychoactive medication ordered for 2 of 15 (#1, #15) patients reviewed. Refer to A-131

Based on interviews and record review, the facility failed to provide medication teaching and obtain informed consent for a neuroleptic psychoactive medication ordered for 2 of 15 (#1, #15) patients reviewed.
Review of medical record revealed, patient #1 was admitted on 6-22-2012, and received medication orders from staff #11 on 6-23-12 at 0230. The order states, " Medication education and informed consent prior to administration of neuroleptic psychoactive. " Patient was ordered Risperdal 0.5mg by mouth twice daily 6/25/12 at 5pm. Staff #17 documented that she administered the medication to the patient on 6-26-12 at 8:34am.
During a phone interview with patient #1, on 10-18-2012 at 1300, patient #1 reported that she had refused the medication Risperdal. Patient #1 reported she did not take the first initial dose offered to her on 6-25-12 at 8:00am. Patient #1 reported she refused, due to absence of teaching material from administering nurse on medication side effects, dosage, or general information.
Review of medical record revealed the Medicare Certification Form, dated 6-26-12 at 8:00am, shows Staff #11 documented the patient, " refused Risperdal as she did not know what it was for. " Upon chart review on patient #1 no evidence of informed consent for psychoactive medications, written or verbal teaching.
On 10-24-2012 at 1018AM an interview with Staff #1 confirmed there was no teaching or informed consent for medication, Risperdal, in the medical record. Staff #1 stated, " I guess they didn ' t do it. "
Review of medical record revealed, patient #15 was admitted on 6-7-2012, and received medication orders from staff #11 on 6-7-12 at 1800. The order states, " Medication education and informed consent prior to administration of neuroleptic psychoactive. " Patient was ordered Risperdal 1mg by mouth twice daily 6/7/12 at 1800. Staff #19 documented medications, Risperdal, administered to the patient on 6-8-12 at 1044AM. Upon chart review on patient #15 no evidence of informed consent for psychoactive medications, written, or verbal teaching was found in the medical record.

Based on document review and interview the facility failed to (A) ensure patient care was provided by the order of a physician for 1 of 15 (#2) patients. The facility failed to ensure 1 of 15 (#2) patients were assessed and monitored for safety while hospitalized in the facility. The facility also failed to follow their own policy to maintain safe management of aggressive or destructive behavior which led to patient #2 being removed by police and charged with terroristic threats. (B) The facility failed to ensure the emotional safety of 1 of 15 (#1) patients by not facilitating a room change requested by the patient.

(A) On 10/23/2012 in the conference room the medical record (MR) for Pt. #2 was reviewed and revealed the following from the Psychiatric Emergency Department (PED) record:
Patient #2 arrived at the Psychiatric Emergency Department On 7/6/2012 (Friday) at 1248 (military time) on an Emergency Detention Warrant. Patient (Pt) #2 was angry, upset, unable to redirect on arrival. A call was placed at 1255 to Dr. #11 and received order for emergency medication. At 1305, Pt. #2 was medicated with Zyprexa 15 Milligrams (mg) and Benadryl 50 mg given IM (intra muscular). At 1405, Pt. #2 was asleep, no distress noted.

Further review of the PED record revealed on 7/6/2012 at 2043, MD Staff #12 conducted medical clearance via remote telemed from the facility's main emergency department. Staff #12 also gave verbal orders to "force fluids and to repeat the Basic Metabolic Panel in the morning. If patient's sodium level was still elevated, patient was to be sent to the acute ED for intravenous rehydration. Review of lab results from 7/6/12 revealed patient's sodium, total protein and albumin were all elevated. At 2215, Admission orders were written to admit Pt #2 to the in-patient acute unit of the behavioral center with admission diagnosis of Schizophrenia, Paranoid Type and Dehydration. An order for routine Zyprexa 10 MG (milligrams) by mouth twice a day was given on admission. Further review of Pt. #2's medical record from the in-patient behavioral health unit revealed the lab work ordered on admission was done and Sodium remained elevated. The facility failed to follow the order to have the patient sent to the ED for intravenous fluids to rehydrate patient.

Review of the electronic nurses' notes for 7/7/2012 (Saturday) at 0136 revealed admission nursing assessment was initiated with this statement, Pt. states he is sleepy and wants to go to sleep". The nursing assessment recorded the following for all general assessment questions. "Pt. refuses to answer question for this assessment. Information comes from the chart from last admit to this facility, emergency detention paperwork". The record indicated the assessment was complete at 0204. There was no documentation that additional attempts were made to conduct the assessment. Documentation of the Direct Care Precaution Flow Sheet for 7/7/2012 at 0145 reflects Pt. #2 was asleep from 0145 until 0615. There was a 4 hour and 15 minute gap in nursing documentation for Pt #2's new admission status from 0419 until 0853. Further review on nurses' notes revealed the RN shift assessment was noted on 7/7/2012 at 0853, but no further nursing documentation was noted until 7/7/2012 at 1747 when nursing documentation revealed "Pt. #2 mood, frustrated and withdrawn. Seclusive to self. Not attending group". There was an 8 hour and 54 minute gap in nursing documentation.

Further review of nursing documentation revealed RN shift assessment was performed at 1743 but copies of the electronic medical record provided did not contain the elements and findings of that shift assessment. A note written at 1751 revealed "Patient inquires about his medication, when told it was Zyprexa, patient stated that he hated to start it because he could not afford it when he left the hospital. Will convey patient's concerns to physician in report. Nursing general note documented at 1851 revealed "Patient is alert and oriented to person, place, and situation. Hallucinations not noted, patient denies A/V (audio/visual) hallucinations, no apparent signs/symptoms of responding to external stimuli. Patient is very guarded. Will approach staff with his needs. Appetite is good. No physical complaints voiced. Good visit observed with his mother. Will continue to monitor patient and precautions. " Documentation at 1900 revealed "Pt. reached up above the stairwell and ripped the metal exit sign down. Nurse asked the patient for the sign and patient stated he was the OSHA inspector. Patient paced back and forth and refused to relinquish the sign. Patient was offered medication and he refused, then he turned to nurse and said that he believed we were going to burn his genitals off and he was getting out of the hospital. Then he suddenly screamed, ' I ' m gonna beat the f--- out of you. Get the f--- away
from me! ' and drew back the sign as if to strike the nurse. Nurse backed up and male Mental Health Technician approached patient who had previous rapport with him but he would not relinquish the sign either. House supervisor was notified. Silent code (Code White) was called due to fear that overhead call would agitate patient further and cause him to start hitting others with the sign. Dr. was notified and he gave orders to call the police. Police were called. Meanwhile patient began to strike the water fountain with the metal sign and broke off part of it. 1915 - Police arrived. Pt. was making statements about cutting pretty faces. Police disarmed patient and he was taken into custody. 1930 - Patient left the floor in police custody." There was no other nursing or physician documentation found in the patient's record.

Review of Policy #3.00036 titled "Safety Management Program-Crisis Intervention: "Code White" revealed the following:

"A. The goal of crisis intervention is to maintain safe management of aggressive or destructive
behavior.

B. When it becomes apparent that additional staff support is required to maintain safety, staff will
page for "Code White" to the area of need.

C. The following personnel trained in CPI will respond immediately by proceeding to the scene:
1. All on-duty Engineering personnel.
2. Nursing Directors/Nursing Supervisor.
3. Other available personnel with appropriate training or experience.

D. Once staff have responded and are present, attempts to intervene using least restrictive measures
will be made before secluding or restraining the patient. Staff will strive to diffuse the situation by
calming the patient and pursuing a resolution to the conflict.

E. Force will be used only to subdue and restrain persons who are behaving violently and
endangering themselves or others. Threats of violence will be dealt with in a non-violent manner.

F. Instances of activation of "Code White" will be reviewed (see attachment) to determine if there were any interventions or other staff actions which might have prevented the crisis."

This policy did not address calling for law enforcement assistance and there was no policy to address that type of intervention.

The facility failed to follow their own policy by not calling the "Code White" before attempting to intervene. One Nurse and one Mental Health Technician attempted to disarm the patient and "offered" medication without appropriate assistance. The nursing documentation revealed no interventions to subdue or restrain the patient and no emergency medications were attempted.

Review of the second PED record for patient #2 revealed patient was returned to the PED by county sheriff ' s department on a emergency detention warrant on 7/8/2012 at 2115. Nursing documentation reads "Per emergency detention report: Pt #2 was aggressive toward staff at the behavioral unit. Pt #2 broke exit signs off the building. Pt #2 threatened to assault behavioral staff with the exit signs that he ripped off the wall. Pt #2 spoke of how he believed the air was toxic and that his genitals were on fire". (All information in the emergency detention report was information pertaining to Pt. #2's admission on 7/6/12 - 7/7/12) Continued review of Nursing documentation for 7/9/12 at 0218 revealed patient was seen by physician for initial examination via telemed and medically cleared for discharge from the PED to the behavioral center for evaluation.

Further review of nursing documentation dated 7/9/12 at 0256 revealed: "Reassessment of Chief Complaint: General: REMAINS EASILY AGITATED. DOESN'T FEEL HE NEEDS TO BE HERE. STATES EVERYTHING ON THE EMERGENCY DETENTION PAPER "IS A LIE" . AFFECT AND MOOD LABILE. RESPIRATIONS EVEN AND UNLABORED NO DISTRESS NOTED. AT PRESENT TIME SITTING IN THE INVOLUNTARY AREA WATCHING T.V. NO COMPLAINTS VOICED AT THIS TIME. Condition: stable PLANS TO TRANSFER TO RUSK. TO REMAIN IN THE ADMISSION DEPARTMENT INVOLUNTARY AREA UNIT MORNING. Prescriptions given-none given. Patient Valuables: Patient without valuables. Patient escorted to discharge desk. 0300: Patient left the ED(emergency department).

Further review of record revealed no nursing documentation after that discharge information until 0700 when the nursing shift changed and the following documentation was found:
"0700: No apparent distress. Report received on a 26 year old African American male in involuntary area. No noted or reported distress at this time. 0900-No apparent distress. Resting quietly. No distress reported. 1030-No apparent distress. 1200-Eating lunch and no voiced complaints or concerns noted or reported. 1330-Patient is up walking around in involuntary area. No aggressive behavior noted at this time. 1500-No apparent distress. Sitting in involuntary area. Will continue to monitor." Review of this record revealed the documentation stopped with the last entry at 1500. A precaution flow sheet dated 7/8/12 and 7/9/12 revealed routine monitoring by direct care staff every 15 minutes that documented patient was in the Involuntary Admissions area from 7/8/12 at 1830 until 7/9/12 at 1815. The monitoring flow sheet reflects no inappropriate, aggressive, or threatening behavior. There was no documentation of psychiatrist or mental health authority being contacted, and no documentation of interventions or medications provided.

On 10/24/2012 in the conference room staff #1, the Assistant Director of Nurses was interviewed and confirmed the Nursing documentation in Pt #2's MR for 7/8/12-7/9/12 did not record the patients' care, treatment, or disposition. Staff #1 reported she was unaware of the disposition of the patient and had no explanation of why the nursing documentation stopped at 1500.


An interview was conducted with the Commanding Officer for the County Sheriff's department on 10/25/2012 at the county detention center. The officer was interviewed and reported the following: Facility staff called for law enforcement to come to the behavioral unit and remove Pt #2 from the behavioral center on 7/7/12 due to threatening and destructive behavior. Pt. #2 was arrested and removed from the facility by the city police department on charges of terroristic threats and criminal mischief. The city police officer also did a Peace Officer's Warrant for Emergency Detention on 7/7/2012 that was good for 24 hours. Pt. #2 was taken to the county jail for detainment. On 7/8/12 at approximately 1720, the sheriff' ' s department returned the patient to the facility for evaluation on the Emergency Peace Officer ' s Warrant from 7/7/12. On 7/9/12 at approximately 1727, city police officers were dispatched to the facility to assist with a mental patient. The police officer was met by the administrator who reported the same information as what had been reported on 7/7/12 when the police department was called to assist with patient #2. The administrator reported patient had been given medication and was in the day room. The officer documented that patient was asleep on the couch. Again on 7/9/2012, charges of terroristic threats were filed against Pt. #2 as well as another Police Officer Emergency Detention Warrant. The Commanding Officer provided copies of all the police reports pertaining to Pt. #2 from 7/6/12-7/9/12 which confirmed the information he had provided. The Commanding Officer also provided a list, given them by the facility, indicating they (the facility) would not admit the following patients. The list contained nine (9) male patients. Pt #2's name was listed. The list had been updated 7/10/2012.





32143

(B) Upon medical chart review, the patient was a 64 year old white female, who came to the PED on 6/23/12 at 0128 involuntary with police escort. The Emergency Detention Warrent was initiated by spouse. She was admitted 6/24/12 at to the Senior Care behavioral unit with a diagnosis of Major Depressive Disorder with Psychotic Features. The patient had gotted a protective order against husband on 6/22/12 for alledged physical abuse and he was served the morning of 6/23/12. Spouse initiated the Emergency Detention Warrent the afternoon of 6/23/12 reporting she was aggressive and paranoid. According to the record the patient was alert and oriented times three. She was in no distress, comfortable, well developed, with anxiety. Patient was cooperative and denied homicidal or suicidal ideations. she was talkative but able to redirect. Patient was admitted to the floor at 0416 6/23/12. Patient was taking Zoloft and Ambien as home medications. Patients urinalysis was positive for Amphetemines and Opiates.
Patient #1 stated during an interview on 10-18-12 at 1300 that she had asked for a room change when she first arrived. Patient #1 stated that she was in a room with a patient that was yelling out. She stated the roommate keep getting in bed with her and patient #1 asked to be moved. Patient #1 stated she was put in a dirty seclusion room with no bathroom and windows uncovered for others to see in. Patient #1 stated she was put in the seclusion room for two nights until she was moved to another patient room. Precaution flow sheet shows patient stayed in a seclusion room on 6-24-12.
During interview and facility tour with staff #2 he stated that the seclusion rooms are used if people feel insecure in their rooms. He stated the doors are not locked but if the patients want to sleep in a different area, this is an option.

Based on record review and interview the facility failed to insure nursing staff met the needs of 1/15 patients identified. The facility failed to insure the nursing staff carried out physician's orders that included failure to administer medications and failure to follow patient treatment orders. The facility failed to insure the nursing staff followed established policies.

On 10/24/2012 at 1:00 PM in the conference room the medical record (MR) for patient (Pt) #2 was reviewed and revealed on 7/6/2012 at 1511(military time) Pt #2 had a blood sodium level of 150. Normal values are 137-145. At 2040 the physician wrote an order to "Force Fluids" and recheck Pt #2's blood sodium level in the morning. The physician continued the order to send Pt #2 to the emergency department (ED) for IV (intravenous) fluids if the sodium level remained elevated. On 7/7/2012 at 0850 the laboratory report revealed Pt #2 had a blood sodium level of 146.

Further review of the MR revealed nursing staff failed to document extra fluids were offered and failed to initiate a fluid intake record to track the fluid intake for Pt #2. Direct care staff documentation reflected meal intake for Pt #2. The record was electronically signed by the direct care staff, staff #12.

Further review of Pt #2 MR revealed nursing staff failed to assess Pt #2's likely dehydration. Nursing staff failed to document action taken when Pt #2 continued to have an elevated blood sodium level of 146. Nursing documentation does not reflect Pt #2 was transferred to the ED for IV fluids. Nursing staff failed to document the physician had been notified of the marginally elevated blood sodium level. Nursing staff failed to document the physician changed or canceled the order. Nursing staff failed to carry out the physician's order for Pt #2.

Further review of Pt #2 MR revealed on 7/6/2012 at 2215 an order for routine Zyprexa 10 MG (milligrams) by mouth twice a day was given by the psychiatrist. Review of Pt #2 MR revealed the nursing staff failed to transcribe the physician's order for routine Zyprexa to the Medication Administration Record (MAR). The MAR did not reflect that the Zyprexa 10 mg by mouth had been given or if it had been refused by Pt #2. Nursing staff failed to document on Pt #2 MAR after admission to the in-patient unit.

Further review MR revealed nursing documentation 7/7/2012 at 0136 for Pt #2's admission nursing assessment began. The nurses note reflect the following" Pt states he is sleepy and wants to go to sleep". (Pt #2 had received two (2) intra muscular (IM) doses of Zyprexa and Benadryl while waiting in the involuntary admissions department that contributed to his sleepy state.) Nurses notes reflect Pt #2 "answered a few questions and went to bed. He was unable to sign because he was drowsy". The direct care staff Precaution Flow Sheet reflects Pt #2 was asleep from 0145 until 0615.

Further review revealed the nursing staff failed to assess Pt #2. Nurses note reflect the following for all general assessment questions. "Pt refuses to answer question for this assessment information comes from the chart from last admit to this facility, emergency detention paperwork". The nursing staff failed to document the initial assessment was revisited once Pt #2 was awake and able to participate.

Further review of MR revealed Pt #2's Patient Bill of Rights, as well as all other admission documents requiring Pt #2 signature, reflected the nursing staff documented "Pt refused". Documentation reflect the nursing staff failed to explain the Patient Bill of Rights to Pt #2. Nursing staff failed to document attempts were made to explain the Bill of Rights or have Pt #2 sign his Bill of Rights once he was awake. On 7/7/2012 at 0203 nursing documentation reflected the admission assessment was completed and two hours later at 0419 the nurses documentation reflected Pt #2 "rested quietly this shift... "

On 10/24/2012, in the conference room, Policy 3.3.5.1 was reviewed and revealed the following: Found under process standards section "C" Upon arrival to the hospital, the patients rights of persons apprehended for emergency detention as contained in the Patient's Bill of Rights, must be provided and explained to the patient by hospital staff.

Further review revealed Pt #2 was admitted on 7/6/2012 with suicidal ideation and was on suicide precautions. Nursing staff failed to document on the admission status of Pt #2 who was under suicidal precautions, from 0419 until 0834.

On 7/7/2012 at 0834 staff RN #14 began documentation. Staff #14 continued to document "pt has not attempted to harm self or others, has not had any episodes of aggression... Patient refused medication and is not medication compliant, is not interacting with others and is not attending group sometimes". Staff nurse #14 failed to document the psychiatrist was made aware of the refusal to take his medication or that Pt #2 was not consistently attending group sessions.

Further review revealed Pt #2 remained on suicide precautions. Nursing staff failed to document on Pt #2 from 0834 until 1742.

Continued MR review revealed the following: On 7/7/2012 at 1742 LVN staff #16 records Fall Risk Assessment performed. The direct care staff's Precaution Flow Sheet records patient in the day room watching television and bizarre.(no explanation or clarification). Nursing staff failed to document assessment or interventions for Pt #2's bizarre behavior.

Further MR review revealed on 7/7/2012 at 1900 nursing documentation reflected the following: "Pt (Pt#2) reached up above the stair well and ripped the metal exit sign down. Sign still had metal screws sticking out of them". The pt refused to relinquish the sign and Pt #2 threatened nursing staff. Nursing staff documentation reflected the "supervisor was called, the physician was called". On 7/7/2012 at 1900 Physician order reads "Phone police due to Pt brandishing a weapon". 7/7/2012 1912 nurses documentation reads "Police arrive...police disarmed patient and he was taken into custody". The nursing staff failed to acquire a discharge order from the physician when Pt #2 left the building under police custody.

On 7/8/2012 at 2115, Pt #2 was returned to the PED by local law enforcement.

A Review of Pt #2 MR for the admission on 7/8/2012 revealed the following: PED nursing staff document "Per emergency detention report "Pt #2 was aggressive toward staff at the behavioral unit. Pt #2 broke exit sign off the building. Pt #2 threatened to assault behavioral staff with the exit sign that he ripped off the wall. Pt #2 spoke of how he believed the air was toxic and that his genitals were on fire" The PED nursing staff documented method of arrival, law enforcement. PED nursing staff failed to acquire a copy of the EDW from police for Pt #2's MR.

Further review of Pt #2 MR revealed that initial lab was ordered and a new patient medical screening was completed for Pt #2, clearing him for discharge from the PED to the behavioral center for evaluation. Nursing staff documented at 0218 discharge was ordered by the medical doctor and at 0300 the patient left the ED. Medical staff failed to document further in Pt #2 MR.

PED nursing staff continue to document on Pt #2 and on 7/9/2012 at 0256 nursing staff documentation reflected "stable, plan to transfer to Rusk. To remain in the admission department involuntary area unit until morning". Medical Staff failed to document support of this plan. Nursing documentation continues until 1500 hours. After 1500 hours nursing staff failed to document a MR for Pt #2.

The direct care staff documented every 15 minutes from 1830 on 7/8/2012 until 1815 7/9/2012 the following. Pt #2 was sitting and visible,pacing, watching Television, laying down, eating, walking or standing. Pt #2 was detained nearly 24 hours in the PED without a documented physician plan or treatment, and without nursing intervention on the patient's behalf after 1500 hours. There was no discharge order located for Pt #2.

On 10/24/2012 in the conference room staff #1, the Assistant Director of Nurses was interviewed and confirmed the nursing staff failed to document when Pt #2 was transferred from the PED, if he was transfer to Rusk, if he was transfer elsewhere, when he actually left the PED, how he left the PED or who he left the PED with.

A review of facility variance reports (incident reports) revealed no report for pt #2 on 7/6/2012, 7/7/2012, 7/8/2012 or 7/9/2012 was identified. There was no documentation the nursing staff had completed a variance report on Pt #2.

On 10/15/2012, via phone conversation, Pt #2's grandmother reported Pt #2 had been arrested on 7/9/2012.

On 10/25/2012 at the county detention center, the officer (personnel #9) in charge was interviewed and revealed the facility staff called for law enforcement to come to the behavioral unit and remove Pt #2 from the behavioral center on 7/7/2012 and again on 7/9/2012 and charges had been filed.

On 10/31/2012, via telephone interview, City police staff confirmed the following:
City police officers removed Pt #2 from the facility and transported him to the county detention center on 7/7/2012 and 7/9/2012. The arresting officer recorded, on 7/9/2012 at approximately 1727 hours he was dispatched to the behavioral center where staff #2 reported Pt #2, threatened to "scar him up using screws". Staff #2 reported Pt #2 had been given medication and was in the day room. "I observed (Pt #2) lying on a couch asleep in the day room. Staff #2 reported he was afraid for his safety because of the size and mental state of Pt #2.

A final review of the MR for Pt #2 revealed while nursing staff had failed to document vital behavioral information for Pt #2, direct care staff documented every 15 minutes from 1830 on 7/8/2012 until 1815 7/9/2012. Direct care documentation reflected no outburst of violence, verbal or physical threats, or aggression were observed. Review of physician documentation from the PED screening indicates "No medications were administered" .

Based on record review, nursing staff failed to follow the physician's orders and administer prescribed anti-psychotic medication to 1 of 15 (#2) patients identified.

On 10/24/2012 in the conference room, review of Pt #2 MR revealed following: Pt #2 was admitted for psychiatric treatment at the behavioral center. On 7/6/2012 at 2215 an order for routine Zyprexa 10 MG (milligrams) by mouth twice a day was given by the psychiatrist.

Further review of Pt #2 MR revealed the Nursing staff failed to transcribe the Zyprexa 10 mg, to be given routinely twice a day by mouth, on to the medication Administration Record (MAR). The nursing staff failed to document on the MAR, if Zyprexa 10 mg had been given to Pt #2 or if Pt #2 had refused to take the routine Zyprexa.

Further review of Pt #2 MR revealed nurses notes reflected Pt #2 refused his medication 7/7/2012 and that Pt #2 was non compliant with medication. However, nursing staff failed to document the Psychiatrist was notified, Pt #2 refused his medication.

Review of Pt #2 MR reveals no physician orders to discontinue or change the medication Zyprexa, which is an anti-psychotic drug. Further more the Psychiatrist dictated Pt #2 discharge summary for 7/7/2012 that reflected Pt #2 was taking Zyprexa twice a day routinely at the time of discharge. Nursing documentation revealed the drug had never been given to Pt #2.

Based on medical record review, document review and interview the facility failed to insure nursing and medical staff provide a complete medical record that accurately reflected the care received by 1/15 psychiatric patients identified.

On 10/24/2012 in the conference room the medical record (MR) for patient (Pt) #2 was reviewed and revealed on 7/6/2012 at 1511(military time) Pt #2 had a blood sodium level of 150. Normal values are 137-145. At 2040 the physician wrote an order to "Force Fluids" and recheck Pt #2's blood sodium level in the morning. The physician continued the order to send Pt #2 to the emergency department (ED) for IV (intravenous) fluids if the sodium level remained elevated. On 7/7/2012 at 0850 the laboratory report revealed Pt #2 had a blood sodium level of 146.

Further review of the MR revealed nursing staff failed to document extra fluids were offered and failed to initiate a fluid intake record to track the fluid intake for Pt #2. Direct care staff documentation reflected meal intake for Pt #2. The record was electronically signed by the direct care staff, staff #12.

Further review of Pt #2 MR revealed nursing staff failed to assess Pt #2's likely dehydration. Nursing staff failed to document action taken when Pt #2 continued to have an elevated blood sodium level of 146. Nursing documentation does not reflect Pt #2 was transferred to the ED for IV fluids. Nursing staff failed to document the physician had been notified of the marginally elevated blood sodium level. Nursing staff failed to document the physician changed or canceled the order. Nursing staff failed to carry out the physician's order for Pt #2.

Further review of Pt #2 MR revealed on 7/6/2012 at 2215 an order for routine Zyprexa 10 MG (milligrams) by mouth twice a day was given by the psychiatrist. Review of Pt #2 MR revealed the nursing staff failed to transcribe the physician's order for routine Zyprexa to the Medication Administration Record (MAR). The MAR did not reflect that the Zyprexa 10 mg by mouth had been given or if it had been refused by Pt #2. Nursing staff failed to document on Pt #2 MAR after admission to the in-patient unit.

Further review MR revealed nursing documentation 7/7/2012 at 0136 for Pt #2's admission nursing assessment began. The nurses note reflect the following" Pt states he is sleepy and wants to go to sleep". (Pt #2 had received two (2) intra muscular (IM) doses of Zyprexa and Benadryl while waiting in the involuntary admissions department that contributed to his sleepy state.) Nurses notes reflect Pt #2 "answered a few questions and went to bed. He was unable to sign because he was drowsy". The direct care staff Precaution Flow Sheet reflects Pt #2 was asleep from 0145 until 0615.

Further review revealed the nursing staff failed to assess Pt #2. Nurses note reflect the following for all general assessment questions. "Pt refuses to answer question for this assessment information comes from the chart from last admit to this facility, emergency detention paperwork". The nursing staff failed to document the initial assessment was revisited once Pt #2 was awake and able to participate.

Pt #2's Patient Bill of Rights, as well as all other admission documents requiring Pt #2 signature, reflected the nursing staff documented "Pt refused". Documentation reflect the nursing staff failed to explain the Patient Bill of Rights to Pt #2. Nursing staff failed to document attempts were made to explain the Bill of Rights or have Pt #2 sign his Bill of Rights once he Further review of MR revealed was awake. On 7/7/2012 at 0203 nursing documentation reflected the admission assessment was completed and two hours later at 0419 the nurses documentation reflected Pt #2 "rested quietly this shift... "

On 10/24/2012, in the conference room, Policy 3.3.5.1 was reviewed and revealed the following: Found under process standards section "C" Upon arrival to the hospital, the patients rights of persons apprehended for emergency detention as contained in the Patient's Bill of Rights, must be provided and explained to the patient by hospital staff.

Further review revealed Pt #2 was admitted on 7/6/2012 with suicidal ideation and was on suicide precautions. Nursing staff failed to document on the admission status of Pt #2 who was under suicidal precautions, from 0419 until 0834.

On 7/7/2012 at 0834 staff RN #14 began documentation. Staff #14 continued to document "pt has not attempted to harm self or others, has not had any episodes of aggression... Patient refused medication and is not medication compliant, is not interacting with others and is not attending group sometimes". Staff nurse #14 failed to document the psychiatrist was made aware of the refusal to take his medication or that Pt #2 was not consistently attending group sessions.

Further review revealed Pt #2 remained on suicide precautions. Nursing staff failed to document on Pt #2 from 0834 until 1742.

Continued MR review revealed the following: On 7/7/2012 at 1742 LVN staff #16 records Fall Risk Assessment performed. The direct care staff's Precaution Flow Sheet records patient in the day room watching television and bizarre.(no explanation or clarification). Nursing staff failed to document assessment or interventions for Pt #2's bizarre behavior.

Further MR review revealed on 7/72012 at 1900 nursing documentation reflected the following: "Pt (Pt#2) reached up above the stair well and ripped the metal exit sign down. Sign still had metal screws sticking out of them". The pt refused to relinquish the sign and Pt #2 threatened nursing staff. Nursing staff documentation reflected the "supervisor was called, the physician was called". On 7/7/2012 at 1900 Physician order reads "Phone police due to Pt brandishing a weapon". 7/7/2012 1912 nurses documentation reads "Police arrive...police disarmed patient and he was taken into custody".

On 7/24/2012 in the conference room a review of Rules and Regulation of the Medical Staff for the behavioral center revealed section II at 2.3- Patients shall be discharged only on the order pf the attending physician. At the time of discharge, the attending physician shall see that the record is complete, state his/her diagnosis and sign the record. Record review for PT #2 revealed the nursing staff failed to acquire a discharge order from the physician when Pt #2 left the building under police custody.

On 7/8/2012 at 2115, Pt #2 was returned to the PED by local law enforcement.

A Review of Pt #2 MR for the admission on 7/8/2012 revealed the following: PED nursing staff document "Per emergency detention report "Pt #2 was aggressive toward staff at the behavioral unit. Pt #2 broke exit sign off the building. Pt #2 threatened to assault behavioral staff with the exit sign that he ripped off the wall. Pt #2 spoke of how he believed the air was toxic and that his genitals were on fire" The PED nursing staff documented method of arrival, law enforcement. PED nursing staff failed to acquire a copy of the EDW from police for Pt #2's MR.

Further review of Pt #2 MR revealed that initial lab was ordered and a new patient medical screening was completed for Pt #2, clearing him for discharge from the PED to the behavioral center for evaluation. Nursing staff documented at 0218 discharge was ordered by the medical doctor and at 0300 the patient left the ED. Medical staff failed to document further in Pt #2 MR.

PED nursing staff continue to document on Pt #2 and on 7/9/2012 at 0256 nursing staff documentation reflected "stable, plan to transfer to Rusk. To remain in the admission department involuntary area unit until morning". Medical Staff failed to document support of this plan. Nursing documentation continues until 1500 hours. After 1500 hours nursing staff failed to document a MR for Pt #2.

The direct care staff documented every 15 minutes from 1830 on 7/8/2012 until 1815 7/9/2012 the following. Pt #2 was sitting and visible,pacing, watching Television, laying down, eating, walking or standing. Pt #2 was detained nearly 24 hours in the PED without a documented physician plan or treatment, and without nursing intervention on the patient's behalf after 1500 hours. There was no discharge order located for Pt #2.

On 10/24/2012 in the conference room staff #1, the Assistant Director of Nurses was interviewed and confirmed the nursing staff failed to document when Pt #2 was transferred from the PED, if he was transfer to Rusk, if he was transfer elsewhere, when he actually left the PED, how he left the PED or who he left the PED with.

A review of facility variance reports (incident reports) revealed no report for pt #2 on 7/6/2012, 7/7/2012, 7/8/2012 or 7/9/2012 was identified. There was no documentation the nursing staff had completed a variance report on Pt #2.

On 10/15/2012, via phone conversation, Pt #2's grandmother reported Pt #2 had been arrested on 7/9/2012.

On 10/25/2012 at the county detention center, the officer (personnel #9) in charge was interviewed and revealed the facility staff called for law enforcement to come to the behavioral unit and remove Pt #2 from the behavioral center on 7/7/2012 and again on 7/9/2012 and charges had been filed.

On 10/31/2012, via telephone interview, City police staff confirmed the following:
City police officers removed Pt #2 from the facility and transported him to the county detention center on 7/7/2012 and 7/9/2012. The arresting officer recorded, on 7/9/2012 at approximately 1727 hours he was dispatched to the behavioral center where staff #2 reported Pt #2, threatened to "scar him up using screws". Staff #2 reported Pt #2 had been given medication and was in the day room. "I observed (Pt #2) lying on a couch asleep in the day room. Staff #2 reported he was afraid for his safety because of the size and mental state of Pt #2.

A final review of the MR for Pt #2 revealed while nursing staff had failed to document vital behavioral information for Pt #2, direct care staff documented every 15 minutes from 1830 on 7/8/2012 until 1815 7/9/2012. Direct care documentation reflected no outburst of violence, verbal or physical threats, and no aggression was observed. Review of nursing admission documentation reflected no physician's order for any medication was found. There was no MAR reflecting a medication had been given to Pt #2 while in the PED prior to being removed by police.