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Based on document review, video surveillance review, and interview, it was determined that for 1 of 1 patient's (Pt. #12) clinical record reviewed on the 6 East Behavioral Health Unit, the Hospital failed to provide the required 1:1 observation (1 staff to 1 patient within an arm's length) to ensure care was provided in a safe setting.

Findings include:

1. On 7/30/2021, the clinical record of Pt. #12 was reviewed. Pt. #12 was admitted to the Hospital due to schizoaffective disorder with increased violent/aggressive behavior. The clinical record included a physician's order dated 7/15/2021 requiring Pt. #12 to have 1:1 observation.

2. On 7/30/2021, the Hospital's policy titled, "Monitoring of Psychiatric Patients" (revised on 3/2019) was reviewed and included, " ... To ensure the appropriate safe monitoring and observation of patients ... B. Higher Level of Safety Precautions ... II. Patients on higher level safety precautions on the psychiatric unit will be monitored every 15 minutes ... unless a physician orders a 1:1 observation for that safety precautions, during which a staff member will be within arms (length) ..."

3. On 7/30/2021 between 4:00 PM and 4:30 PM, a video surveillance review of the 6 East Hallway was conducted with E # 20 (Systems Director for Behavioral Health), E #17 (Peer Review Coordinator) and E #23 (Director of Quality and Regulatory). On 7/28/2021 from 12:00 MN through 2:01 AM, the video surveillance footages showed that there was no staff providing 1:1 observation to Pt. #12.

4. On 7/30/2021 at approximately 4:30 PM, findings were discussed with E #20. E #20 agreed that there was no staff providing 1:1 observation to Pt. #12 on 7/28/2021 from 12:00 AM through 2:01 AM.

A. Based on document review and interview, it was determined that for 3 of 3 patients' (Pt. #2, Pt. #4, and Pt. #5) clinical record reviewed for pain reassessment, the Hospital failed to conduct a pain reassessment after medication administration, as required, to ensure evaluation of the nursing care was provided for each patient.

Findings include:

1. On 7/27/2021, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted to the Hospital on 5/13/2021 due to multiple fractures. The clinical record included:

- A physician's order dated 5/13/2021 for hydromorphone (pain medication) 0.2 mg (milligrams) intravenous injection every three hours, as needed for pain. The medication administration record (MAR) indicated that hydromorphone was given on 5/14/2021 at 9:33 AM. A pain reassessment was conducted on 5/14/2021 at 6:56 PM (approximately 9 hours after medication was administered).

- A physician's order dated 5/14/2021 for oxycodone (pain medication) 10 mg by mouth every six hours, as needed for pain. The MAR indicated that oxycodone was given on 5/15/2021 at 1:02 AM. A pain reassessment was conducted on 5/15/2021 at 3:15 AM (approximately two hours after medication administration).

2. On 7/27/2021, the clinical record of Pt. #4 was reviewed. Pt. #4 was admitted to the Hospital on 7/1/2021 with diagnoses of acute kidney injury and hyperglycemia (high blood sugar). The clinical record included a physician's order for oxycodone 10 mg two tablets every four hours, as needed for pain. The MAR indicated that oxycodone was given on 7/24/2021 at 5:02 AM. There was no pain reassessment after the medication was administered.

3. On 7/27/2021, the clinical record of Pt. #5 was reviewed. Pt. #5 was admitted to the Hospital on 5/16/2021 with a diagnosis of gunshot wound. The clinical record included:

- A physician's order for acetaminophen 650 mg two tablets every six hours, as needed for pain. The MAR indicated that acetaminophen was given on 7/26/2021 at 6:52 AM. There was no pain reassessment after the medication was administered.

- A physician's order dated 7/22/2021 for tramadol (pain medication) 50 mg one tablet every six hours as needed for pain. The MAR indicated that tramadol was given on 7/25/2021 at 4:39 AM. The pain reassessment was conducted on 7/25/2021 at 6:26 AM (approximately two hours after medication administration).

4. On 7/28/2021, the Hospital's policy titled, "Pain Assessment and Management" (revised on 10/2019) was reviewed and included, " ... The purpose of the policy is to establish standards for the assessment, reassessment and management of pain ... Treatment of Pain ... Patients will be monitored for the response to pain relief measures. Pain relief from pharmacological interventions should be assessed by the health care professional one hour after medication administration ..."

5. On 7/28/2021, the Hospital's policy Hospital's policy titled, "Guideline for the Nursing Process" (revised on 10/5/2020) was reviewed and included, " ... V. Procedure ... D. Evaluation. 1. The nurse should document nursing interventions, patient's response to interventions ..."

6. On 7/28/2021 at approximately 1:30 PM, findings were discussed with E #12 (Unit Manager, 2 North). E #12 stated that a pain reassessment should have been conducted at least one hour after medication administration. E #12 could not provide documentation of the pain reassessments after medications were administered.


B. Based on document review and interview, it was determined that for 1 of 1 patient's (Pt. #12) clinical record on the 6 East Behavioral Health Unit with allegation of sexual assault, the Hospital failed to ensure that the physician's recommendation to send patient for sexual assault examination was completed.

Findings include:

1. On 7/30/2021, the clinical record of Pt. #12 was reviewed. Pt. #12 was admitted to the Hospital due to schizoaffective disorder with increased violent/aggressive behavior. The clinical record indicated that Pt. #12 reported on 7/28/2021 that she was sexually assaulted by a staff. The clinical record included a physician's recommendation for a complete sexual assault work-up. As of survey date 7/30/2021, a sexual assault examination has not been completed for Pt. #12.

2. On 7/30/2021, the Hospital's job description for registered nurse in the behavioral health unit was reviewed and included, "General Summary/Basic Purpose of Job: The staff nurse is accountable for the performance of patient care according to the behaviors and responsibilities as outline in this statement ... 3.2. Implements physician and nursing orders as appropriate involving patient ..."

3. On 7/30/2021, findings were discussed with E #20. E #20 stated that the physician's recommendation was for Pt. #12 to have a sexual assault examination. E #20 could not provide documentation why the sexual assault examination was not completed.

Based on document review and interview, it was determined that for 1 of 3 patient's (Pt. #2) clinical records reviewed for medication administration, the Hospital failed to ensure that the medication order was given in accordance with the approved medical staff policies and procedures.

Findings include:

1. On 7/27/2021, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted to the Hospital on 5/13/2021 due to multiple fractures. The clinical record included a physician's order dated 5/14/2021 to administer acetaminophen 650 mg (milligrams) by mouth every six hours, scheduled dose. The clinical record indicated that acetaminophen was given on 5/14/2021 at 5:06 PM then on 5/15/2021 at 1:01 AM (approximately two hours delayed).

2. On 7/28/2021, the Hospital's policy titled, "Medication Administration" (revised on 8/2012) was reviewed and included, " ... To establish nursing procedures for the safe administration and preparation of medication ... V. Procedure ... 1. All medications are administered upon the written order of an authorized prescriber ... Medication Administration ... 10. If a medication is not administered at the proper time ... the nurse should note this. When a dose is delayed or omitted ... the reason for the delay or omission is documented on the MAR (medication administration record) ..."

3. On 7/28/2021, findings were discussed with E #12 (Unit Manager, 2 North). E #12 stated that the medication should have been given as ordered. E #12 added that the reason for the delay should have also been documented. E #12 could not provide documentation for the above findings.