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Based on patient medical record reviews, staff interviews, and policy reviews, the facility failed to evaluate care needs for 2 of 10 pts. sampled Pts. #1 and #2). The facility failed to implement appropriate interventions for Pt. #1 and failed to implement appropriate safety interventions for Pt. #2. The facility failed to take appropriate measures in a timely manner to prevent potential skin breakdown of pt. #1. The facility failed to ensure that all staff were aware that Pt. #2 was on elopement precautions, and failed to assess appropriate interventions to prevent elopement of pt. #2. This failure to take appropriate measures and interventions directly affected Pt. #1 and Pt. #2 and has the potential to affect all patients.

Findings include:
Per Policy entitled "Personal Hygiene of Patients" dated 3/10/2004, under action it states, "If odor is the concern, and the person is not changing his/her clothes, it would be less restrictive to prompt the person, with forced compliance (hold and treat) if necessary, to allow their clothes to be washed. If this does not eliminate the problem, bathing could then become the issue. If there are specific concerns about health issues, the corrective action needs to specifically address that concern."
The following was noted during the review of Pt. #1's medical record beginning at 12:30 p.m. on 10/16/12:
Pt. #1, a 78 year old male, was admitted to the psychiatric hospital unit via chapter 51 on 9/30/12, after becoming aggressive with spouse. Pt. #1 has a primary diagnosis of Alzheimer's Dementia with Behavioral Disturbance and Delusions.
A physician order was written on 10/4/12 at 11:50 a.m. for Haldol 2.5 mg orally or via IM (intramuscular injection) and Ativan 0.5 mg orally or IM every 6 hrs. PRN (as needed) for severe agitation. Per review of the MAR (Medication Administration Record) the Haldol and Ativan were given once during Pt. #1's hospital stay: Haldol orally at 9:00 a.m. and Ativan orally at 9:30 a.m. on 10/6/12.
The 10/5/12 chain of events are as follows per record review:
10:02 a.m. per daily psychiatric notes: Refused morning medications and would not take them until daughter called. Refused breakfast and lunch. BM (Bowel Movement) on floor in room. Defecated on floor yesterday.
10:10 a.m. Social Service note: Declining to get out of bed.
12:10 p.m. Medical progress notes: Technician reported to RN Pt. #1 not eating or drinking. Pt. #1 refuses to clean self and put new clothes on. Pt. #1 "Is laying in bed covered in urine." Last meal intake supper last night. Refused morning medications after multiple attempts.
1:55 p.m. Medical progress note: Morning medications offered repeatedly by 2 nurses and Pt. #1 declined each time. Has been in bed all day without fluids or food, will continue to offer medications, food, and fluids.
3:30 p.m. Nursing progress note: Has not left bed this shift. Refused medications and both meals. Refused to shower, bathe, or change clothes. Refused to take 2 phone calls. Refused anything offered. Has had no fluid this shift. Has been incontinent, but refuses all attempts to clean or change. Becomes agitated when pressed or pressured. DON and Psychiatrist have met with Pt. #1 and are aware of #1's condition. Pt. not voiding because not taking fluids. "Lying in dried urine and has not or will not change clothes. To continue to attempt alternative approaches."
Unsuccessful attempts to provide incontinence care and give medications, food, and fluids were documented by technicians at 3:30 p.m. and 7:10 p.m.
7:10 p.m. Nursing progress note: Attempts made to assist with activities of daily living (ADLs). "Refused to change BM clothing, to drink fluids, and refused supper."
The following is the next nursing documentation after the 7:10 p.m. note on 10/5/12:
10/6/12 documentation:
5:45 a.m. nursing progress note: "Continues to refuse to change clothes and bedding. Gets agitated quickly. Has been in bed all shift and very uncooperative with cares. Refusing every attempt to assist." .
8:00 a.m. nursing progress note: "Took morning medications, declined offers of shower or bath, informed of urine odor, and continues to refuse. Given PRN (As needed) Haldol."
8:45 a.m. medical progress note states spoke with physician regarding Pt. #1's noncompliance with ADLs and no food or fluids. Per physician orders noted at this time: Geoden 10 mg IM 2 times per day as needed for severe agitation.
9:20 a.m. medical progress note states: "Spouse called, declined consent for Geoden, does not want him to have Seroquel." Spouse stated that #1 thinks staff are all prisoners and #1's only defense is to stay away.
10:10 a.m. medical progress note: "Given bed bath, resistive at first, after explained cooperative. Had dry stool on skin and underwear were stained yellow."
Per interview with RN C beginning at 11:50 a.m. on 11/1/12, on 10/5/12 recalls that at 12:10 p.m. a technician reported that Pt. #1 was not eating or drinking and was incontinent. Stated was ready to get an order to force to treat, but other staff (Cannot recall exactly who, but thinks some were technicians) told C that C could not do that as needed a court order to do so. Per C Pt. #1 was not combative when C assessed #1 on 10/5/12, but #1 was, "Just like dead weight and when approached just said no, no, no." Per RN C a physician psychiatrist and DON B were present and aware that pt. #1 was not eating or drinking around 12:00 p.m. on 10/5/12.
Per interview with Administrator A from 1:15 p.m. to 1:35 p.m. on 11/1/12, A said that A does not know why staff failed to implement facility policy regarding a physician order for "hold and treat" earlier than the morning of 10/6/12. A verified that there was some confusion with staff regarding use of "force" for treatment and cares. Staff misunderstood how and when to use force to treat.
Per interview beginning at 2:15 p.m. on 11/1/12, DON B verified that staff did not get an order to hold or attempt to hold Pt. #1 to provide incontinence care after #1 had been incontinent for more than 21 hours. Per B, B left the facility about 1:00 p.m. on 10/5/12 and was aware that Pt. #1 was not eating or drinking.
Per interview with Psychiatric Technician F beginning at 3:35 p.m. on 11/1/12, F stated that by the evening of 10/5/12, Pt. #1 smelled strongly of urine.
Per interview with RN D beginning at 9:45 a.m. on 11/5/12, D stated that staff can always get an order to hold a pt. for cares. Per D an order to hold should have been obtained earlier if staff were not able to provide incontinence care.
Per interview with MSW E beginning at 10:08 a.m. on 11/5/12, E stated that if there are issues that come down to the health and safety of pts. staff can change them (change clothing, provide incontinence care, etc.). Per E, "'forced" means getting a physician order to get a pt. out of bed, change the bed, and clean pt. up.
Per medical record documentation, Pt. #1 was left lying in urine and BM from 12:10 p.m. on 10/5/12 until 10:10 a.m. on 10/6/12. No administration of PRN Haldol or Ativan IM was attempted to be given and no order to hold for ADL cares was obtained until 9:30 a.m. on 10/6/12 . Bathing was not done until 10:10 a.m. on 10/6/12, which is 22 hours after staff documented that #1 was soiled. Interventions and approaches taken to ensure Pt.#1 received food or fluids for 24 hrs. were not documented. Staff were not aware of "force" policy to hold and treat. Nursing failed to coordinate appropriate interventions.
Patient #2
Policy and procedure dated 8/25/2005 entitled "Elopement Risk", states that every pt. must have an elopement risk assessment on admission to the unit. If risk factors are present staff are to place elopement precaution sign outside of the admission door and alert technicians. "Elopement precautions to be implemented:
A. Elopement precaution signs on doors.
B. Notify charge technician.
C. Pt. to be dressed in facility sweats and is not to have shoes.
D. Pt. id to have no money.
E. Place in Report and on the board for on-coming shifts.
F. Written order in chart.
G. Place pt. in room 218, if possible. If not, place in pt. Pod 2 or 3.
H. Strict 5 minute checks.
I. Activate care plan.
The admitting nurse will complete the assessment form upon an admit and activate elopement precautions any time through the patient's stay if any risk factors are present or occur during the admission stay. Psychiatric technicians to report to nurse if any risk factors are noted through stay."
Policy and procedure dated 4/30/2007 entitled "Elopement", states that every pt. must have an elopement risk assessment on admission to the unit and thereafter, as indicated.
"For an observed elopement: Staff will attempt to deter by using the following procedures:
Remind pt. of privilege level being suspended if chooses to elope, alert other staff member per walkie talkie of elopement, follow pt. to keep in sight, do not attempt to physically impede pt. physical path." The policy states to follow notification of: "Treatment Director, police, DON, Administrator, family/guardian/other involved agencies when necessary." "RN Supervisor to document in pt. clinical record complete record of elopement incident, prior behaviors, search, telephone contacts, outcome of incident, and body check."
Policy entitled "Privilege levels" states that in the event that orders are not immediately received at the time of admission, pts. are on level 1 privileges until admission orders are written. The Psychiatrist or Psychologist admitting a pt. determines privilege level.
Level 1 privileges includes: restriction to the unit only, to be on 5 minute checks. Level 1 may use the fenced recreation area with staff supervision, but this may be withheld if the pt. is on a 1:1 due to suicide or elopement risks."
Per medical record review of Pt. #2 beginning at 11:25 a.m. on 10/16/12, it was noted that Pt. #2 was admitted at 1:25 a.m. on 9/25/12 on a chapter 51 hold. Pt. #2's diagnosis include: unspecified drug abuse and history of Bipolar Disorder. The problem list in the front of the medical record lists under #4, "Potential for Elopement" activated by the 9/25/12 night shift nurse RN G.
RN G completed the initial 7 page admission intake form with documentation of the following upon admission at 1:25 a.m. on 9/25/12: "At 12:05 a.m. 9/25/12: Received call from crisis and spoke with officer who reported that Pt. #2 had left a hospital in Wisconsin Rapids AMA (Against Medical Advice). Elopement precautions until reassess tomorrow. Care plan developed for elopement precautions."
A body assessment diagram was filled in for injuries (scars, scratches, bruises etc.) and completed at 1:35 a.m. The picture diagram revealed the following: Left eye scratch and bruise, scratches on left rib area and left flank as well as abdomen., scabs and scratches on both anterior legs, both feet wrapped in bandages, and a scrape on the right elbow.
RN G completed the elopement risk assessment at 1:55 a.m. which has 3 areas with yes answers which include: a previous history of elopement, a substance abuser, and elopement risk activated at admission for 24 hrs.
RN G developed a care plan on 9/25/12 for "Potential for Elopement" with interventions of remaining on 5 minutes checks and restrictive privileges.
Pt. #2's medical record also contains a Wisconsin Rapids police offense report dated 9/25/12 which states that while Pt. #2's father was trying to get Pt. #2 admitted to the Wisconsin Rapids Hospital that evening around 5:00 p.m., Pt. #2 wandered off from the hospital and was returned to the E.R. by police officers. This situation was explained to RN G per phone call prior to transferring pt. to this psychiatric hospital.
An intake evaluation was completed by Psychologist Doctor H and Treatment Director, Doctor I at 10:40 a.m. on 9/25/12, which stated that Pt. #2 is 5 feet and 8 inches tall and weighs 174 pounds. The intake also states that at the time Pt. #2 "wobbly" with ambulation with decreased psychomotor activity, drowsy, slow responses, decreased mentation, and severely compromised due to apparent drug-induced delirium.
Per review of flow sheets, alcohol protocol was initiated at 11:00 on 9/25/12 which includes vital sign, orientation, mental status, motor status, and pupil checks to be done every 2 hours.
At the 11:00 a.m. check the following was marked: oriented x 3 ( to Person, place, and time), alert, hand grasps firm, and pupils brisk.
At the next flow sheet check at 1:00 p.m. it states that #2 is alert x 3, confused, hand grasps firm and pupils brisk. (Changed from alert mental status to confused mental status within the last 2 hrs.).
Staff documented in care plan progress note at 1:00 p.m. that Pt. #2 has flat affect with poor eye contact and no behaviors noted on that shift.
The next care plan progress note is at 3:28 p.m. on 9/25/12 and states that Pt. #2 eloped from facility at this time.
RN C documented the following in medical progress notes at 3:40 p.m. on 9/25/12: Per technician report, Pt. "eloped" while outside in recreation area. Jumped fence. Police called and DON B and Administrator A notified.
Per review of physician orders, at 4:20 p.m. 9/25/12 elopement precautions and unit restricted ordered.
The next note in the medical progress notes is at 4:30 p.m. and written by RN C which states that Pt. #2 was captured by police, needed to be tazed, when brought back to this facility via ambulance Pt. #2 was examined by Dr. J. Noted Pt. #2 to have multiple scratches to back and both elbows. Given 2 mg Ativan and 100 mg Seroquel orally.
The next note in the medical progress notes as at 4:40 p.m. and written by Dr. J which states that police chased Pt. #2 down, tazed #2, called an ambulance, and brought Pt. #2 back to this facility. A brief exam at this facility showed a complete change as was agitated and earlier was very sedated and almost "non responsive". Pt. #2 now had bruising on the back, 4 wounds from the tazer, multiple new areas of bruising on the upper shoulder area and around the chest. Sent to the local E.D. for CAT scan as right pupil enlarged compared to the left one.
At 7:10 p.m. 9/25/12, RN C completed an incident report that stated that Pt. #2 was outside and impulsively climbed and jumped over the fence eloping.
Per medical progress note at 7:25 p.m. 9/25/12, RN G documented that Pt. #2 had returned from E.D. visit after CAT scan negative.
At 8:00 p.m. 9/25/12, RN C completed a new body check after return from the E.D. with the following being noted: An abrasion on the right anterior neck, old bruising and swelling on the left side of the face, abrasions on right anterior shoulder and arms, abrasions on right rib and flank sides, scratches on abdomen, abrasions and bruising on both anterior legs, infected sores on both anterior feet, an abrasion behind the left ear, scrapes on the back of the right shoulder, abrasions on the left elbow and left rib area on the back, and 3 tazer marks on mid back.
During an interview with DON B beginning at 12:07 p.m. on 10/17/12 the facility has never had a pt. jump over the fence before. On 9/25/12 Pt. #2, "Climbed the fence like a monkey." Pt. #2 was about 1 foot away from the high chain linked fence, then quickly climbed the fence so fast that staff could not catch #2 before going over it. Quality indicators are being reviewed for privileges due to this elopement.
Per interview with DON B beginning at 2:15 p.m. on 11/1/12, Pt. #2 was under the influence of drugs on 9/25/12-thinks took cold tablets. B was not aware that Pt. #2 had wandered away from the hospital in Wisconsin Rapids prior to admission here. DON B states that night nurse G failed to communicate elopement precautions to the day shift staff. Per B, RN G failed to put the elopement information on the "board" for day shift staff to see. (Board used for communication). Per B, there was 1 activity staff and 1 psychiatric technician out in the fenced area when the elopement occurred. DON B states that it is facility policy that if pts. are 1:1 and or on unit restriction, the pts. are still allowed to be in the fenced area outside.
Review of MSW M's investigation of the 9/25/12 elopement which M completed on 10/2/12, revealed that M concluded that there was a break-down in communication between nursing staff as to whether Pt. #2 was on or off elopement precautions, but should have remained on them. M added that even if Pt. #2 was on elopement precautions, #2 was allowed to be outside in the fenced in recreation area.
Per MSW M's investigation, it could not be determined who yellowed out the elopement tracking sheet and why the elopement care plan was not readily available for staff to see that #2 was on elopement precautions.
During the 11/1/12 daily exit meeting with Administrator A beginning at approximately 4:20 p.m., Administrator A verified the lack of appropriate care for Pt. #1 and unclear nursing communication for Pt. #2. Nursing failed to implement appropriate safety precautions for Pt. #2 who was known to have elopement risks.

Based on medical record reviews and staff interviews, the facility failed to incorporate pertinent information in the medical records of 2 of 10 pts. sampled (pts. #1 and #2). The facility failed to document interventions for Pt. #1's non-compliance with ADLS. The facility failed to ensure that elopement risk documentation was available, complete, and maintained for elopement precautions of Pt. #2. The failure to document and maintain pertinent information in pt. medical records has the potential to affect all pts.

Findings include:
1.) The following was noted during the review of Pt. #1's medical record beginning at 12:30 p.m. on 10/16/12:
Pt. #1, was admitted to the psychiatric hospital unit via chapter 51 on 9/30/12 after becoming aggressive with spouse. Pt. #1 has a primary diagnosis of Alzheimer's Dementia with Behavioral Disturbance and Delusions.
A 10/5/12 10:02 a.m. daily psychiatric note states that Pt.#1 refused to take medications, refused breakfast and lunch, and that on 10/4/12 defecated on floor.
A 10/5/12 12:10 p.m. Medical progress note state that Pt. #1 continues to refuse medications, food, and fluid; refuses to clean self and put new clothes on. Attempted approaches/interventions not Documented.

Medical progress note documented by RN C at 12:42 p.m. on 10/5/12 states that C notified pt. #1's spouse pt. #2's not eating, drinking, cleansing self, and refusing medications. There is no documentation of what Pt. #2's response was.
A 10/5/12 1:55 p.m. Medical progress note states that Pt. #1 has been in bed all day without fluids or food, and will continue to offer medications, food, and fluids. Approaches attempted and food and fluids offered are not documented.
A 10/5/12 3:30 p.m. Nursing progress note states that Pt. #1 refuses to take medications and meals and refuses to shower, bathe, or change clothes. "To continue to attempt alternative approaches." Documentation lacks interventions attempted and others to consider.
Unsuccessful attempts to provide incontinence care and give medications, food, and fluids were documented by technicians at 3:30 p.m. and 7:10 p.m. Documentation lacks what interventions were attempted.
On 10/5/12 at 7:10 p.m. Nursing progress note states that attempts were made to assist with activities of daily living (ADLs). "Refused to change BM clothing, to drink fluids, and refused supper." Documentation lacks interventions attempted.
Per interview with RN C beginning at 11:50 a.m. on 11/1/12, C recalls that on 10/5/12 contacted Pt. #1's spouse to inform Spouse Pt. #1 was not eating or drinking and discussed if daughter could possible come to attempt to get Pt. #1 to cooperate with cares, medications, and intake. RN C verified that C did not document discussion about possible intervention with Pt.#1's#'s daughter nor spouse's response and should have.

A 10/6/12 5:45 a.m. nursing progress note states that Pt. #1 continues to refuse to change clothes and bedding. "Refusing every attempt to assist." Interventions attempted are not documented.

Per interview beginning at 2:15 p.m. on 11/1/12, DON B verified that B was aware that Pt. #1 was not eating or drinking. B states that staff tried to offer Pt. #1 a variety of fluids including different sodas, juices, and popcicles on 10/5/12, but verifies that it was not documented in the medical record of Pt. #1 as to what types of foods and fluids were offered.

(2.) Per medical record review of Pt. #2 beginning at 11:25 a.m. on 10/16/12, it was noted that Pt. #2 was admitted at 1:25 a.m. on 9/25/12 on a chapter 51 hold. Pt. #2's diagnosis include: unspecified drug abuse and history of Bipolar Disorder. The problem list in the front of the medical record lists under #4, "Potential for Elopement" activated by the 9/25/12 night shift nurse RN G.
Documentation on the 7 page admission intake form by RN G at 1:25 a.m. on 9/25/12 sates that G developed a care plan on 9/25/12 for "Potential for Elopement" with interventions of remaining on 5 minutes checks and restrictive privileges.
Per review of medical progress notes, at 3:40 p.m. RN C documented that per technician report, Pt. #2 eloped while outside.
Per review MSW M's investigation regarding the 9/25/12 elopement of Pt. #2, the following was noted: the tracking sheet for Pt. #2's elopement precautions had been yellowed out (meaning not on elopement precautions). There is no signature or date and time documented on the tracking sheet to indicate which staff yellowed out the tracking sheet and why. The elopement care plan was not readily available for staff to see that #2 was on elopement precautions. M concluded that due to lack of documentation and communication, pt. #2 was taken off of elopement precautions and should not have been.
Per interview with DON B beginning at 2:15 p.m. on 11/1/12, RN G typed up report for the night of 10/5/12 for the following 10/6/12 day shift on the computer. In the report RN G documented the elopement precautions for Pt. #2, but G did not save while typing and the documentation was lost. DON B verified that failure to maintain elopement precaution information, led to a lack of communication so that day shift staff were unaware of Pt. #2's elopement risk and elopement interventions.