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Based on policy and procedure review, medical record review, and staff interview, the nursing staff failed to reassess pain and nausea after medication therapy as per hospital policy for 1 of 1 patients (#1); failed to follow-up on a physician's plan of care, physician orders, and X-ray results for 1 of 1 patients (#1); and failed to initial RN verificaton of Behavior Health patients' 15 minute close oberservation checks for 100 of 196 3-hour blocks of time per hospital policy.

The findings include:

Review of the hospital's policy and procedure titled "Documentation of Patient Assessment in the EHR (Electronic Health Record)", last reviewed 11/2015, revealed ". . . INITIAL ADMISSION ASSESSMENT AND ONGOING REASSESSMENTS An initial assessment will be completed as part of the admission process. Reassessments are completed at the beginning of each shift and on more frequently as needed based upon observations, patient response, patient condition, and the potential changes in patient status. . . . REASSESSMENTS: Reassessments are completed as often as needed based upon observations, patient response to interventions, patient condition, and the potential to develop significant changes. . . ."

Review of the hospital's policy titled "Medication Use Process", last revised 11/2014, revealed ". . . PRN medications must include the name of the drug, dosage, route, frequency and specify reason. The nurse must document the drug information, reason given and evaluation, e.g. pain score, and the evaluation of the effects. . . . "

1. Closed medical record review of Patient #1 revealed an 18 year old male admitted on 04/05/2016 at 1901 with a diagnosis of "Paranoid Schizophrenia (patient has delusions (false beliefs) that a person or some individuals are plotting against them or members of their family)with Acute Exacerbation" and discharged on 04/19/2016 at 1530. Review of Physician's Orders dated 04/06/2016 at 0843 revealed an order for "Zofran ODT (orally disintegrating tablets are used for: Preventing nausea and vomiting) 4 mg (milligrams) po (by mouth) q 6 hrs (every 6 hours) prn (as needed) and Tylenol 650 mg po q 4 hrs prn (every 4 hours as needed)." Review of Medication Administration Record (MAR) dated 04/09/2016 revealed documentation of Zofran ODT 4 mg po administered at 1622. Further review of medical record revealed no available documentation of a reassessment of the effects of the medication therapy given on 04/09/2016 at 1622. Review of Physician's Progress Notes dated 04/09/2016 at 1735 revealed "Patient reports that he is having nausea without vomiting or dry heaves. He states he feels queasy at times. He reports being able to eat his whole meal without emesis...Reports medication side effects: Nausea..." Review of Nurse's Notes revealed a pain assessment dated 04/10/2016 at 1224 with documentation of "headache 7/10 (rated a 7 on a pain scale of 0-10, 10 being the worst). Review of MAR dated 04/10/2016 revealed Tylenol 650 mg po administered at 1224. Further review of Nurse's Notes revealed a pain assessment dated 04/10/2016 at 2145 (8 hours and 16 minutes later). Review of MAR dated 04/12/2016 revealed Zofran ODT 4 mg po administered at 0750. Review of Nursing Shift Summary/Plan of Care dated 04/12/2016 at 1502 revealed "Patient was non cooperative during assessment. Patient stated he didn't feel good. Complained of nausea, PRN Zofran 4 mg given orally @ 0750. Patient refused breakfast when called..." Further review of medical record revealed no available documentation of a reassessment of the effects of the medication therapy given on 04/12/2016 at 0750.

Interview on 05/25/2016 at 1110 with Administrative Staff (AS #1) revealed "Nurses should document in the nursing flowsheets a reassessment for any pain medications or prn medications within 1 hour after administration." Interview confirmed there was no available documentation of a nursing reassessment after Zofran medication therapy. Interview confirmed there was no available documentation of a pain reassessment within 1 hour of Tylenol medication therapy.

Interview on 05/25/2016 at 1420 with Behavioral Health Nurse (RN #3) revealed "We should reassess patients between 30 minutes to 1 hour to see if medication effective or ineffective. I don't recall giving medication specifically."

Interview on 05/26/2016 at 0940 with Behavioral Health Nurse (RN #2) revealed "Patient complained of nausea on 04/12/2016 and gave Zofran 4 mg at 0750. We should have reassessed nausea within 30 minutes to 1 hour. If medications are not effective, I would call the provider and make him aware. Providers are at the hospital daily."

Review of the hospital's policy and procedure titled "Documentation of Patient Assessment in the EHR (Electronic Health Record)", last reviewed 11/2015, revealed ". . . INITIAL ADMISSION ASSESSMENT AND ONGOING REASSESSMENTS An initial assessment will be completed as part of the admission process. Reassessments are completed at the beginning of each shift and on more frequently as needed based upon observations, patient response, patient condition, and the potential changes in patient status. . . . REASSESSMENTS: Reassessments are completed as often as needed based upon observations, patient response to interventions, patient condition, and the potential to develop significant changes. . . ."

2. Closed medical record review of Patient #1 revealed an 18 year old male admitted on 04/05/2016 at 1901 with a diagnosis of "Paranoid Schizophrenia with Acute Exacerbation" and discharged on 04/19/2016 at 1530. Review of Nursing Shift Summary/Plan of Care dated 04/12/2016 at 1502 revealed "Patient became very agitated and didn't comprehend that his tray (breakfast) was kept in the nurses station, he began pacing around his room, punching his walls, flipping his bed, staff reported him hitting his head on the wall also...patient was bleeding from his right hand..." Further review of Physician's Progress notes dated 04/12/2016 at 1739 revealed "...He showed me his hand and has some superficial laceration in his right thumb and order TAO (Triple Antibiotic Ointment) applied tonight. Presently denies pain and was able to flex it..." Review of Physician's Progress Notes dated 04/13/2016 at 1650 revealed "...4. Hand pain, left...After hitting wall last night. Some pain on palpation of 5th metacarpal (long bone in hand). Obtain plain film. If + (positive), splint and have him f/u (follow up) with ortho. If negative, supportive care. Thanks for the consultation. We'll sign off. Please call with any further questions/concerns...Subjective: Pt states his left hand hurts...Physical Exam: ...extr (extremity)-+ pain on palpation of left 5th metacarpal. Neurovascularly intact..." Review of Physician's Orders dated 04/13/2016 at 1650 revealed an order for "X-ray hand 2 views Left." Review of Nursing Shift Summary/Plan of Care dated 04/13/2016 at 1759 revealed "...He was escorted downstairs for X-ray of left hand which showed a minimally displaced fracture of the distal fifth metacarpal..." Review of Physician's Progress Notes dated 04/14/2016 at 1058 revealed "Assessment: ...Patient Active Problem List Diagnosis ...Hand pain, left..." Review of Physician's Orders dated 04/14/2016 at 1242 revealed a telephone order for "View X-rays and give recommendations." Review of Nursing Shift Summary/Plan of Care dated 04/15/2016 at 1103 revealed "...Patient acquired small cut to the right hand closed to his thumb on Tuesday when patient had an angry outburst, appears to be healing, no redness or swelling, med nurse applied neosporin cream to the small cut and applied a band aid..." Further review of medical record revealed no available documentation of any follow-up by nursing for physician's plan of care written on 04/13/2016 at 1650, Left Hand X-ray results on 04/13/2016 at 1741 or physician's orders written on 04/14/2016 at 1242.

Interview on 05/25/2016 at 1110 with Administrative Staff (AS #1) revealed "It is the responsibility of the psychiatrist to follow-up on any recommendations from the medical consult. No order required for TAO. It is kept in their stock items, like getting a Band-Aid. Nurses should document any abnormal findings and injuries in the nursing flowsheets." Interview confirmed there was no available documentation of a nursing reassessment of patient's left hand after X-ray and no documentation of a splint being placed.

Interview on 05/26/2016 at 1015 with Administrative Staff (AS #2) revealed "Psychiatry provider is responsible for carrying out plan of care for medical consult."

Interview on 05/25/2016 at 1409 with Medical Provider (MD #1) revealed "I would not write the order for splinting because the X-ray had not been completed at the time I saw the patient and signed off. I would expect the nurse or primary team (psychiatry) to have written the order after X-rays resulted. I would have been happy to write the splint order, had the X-rays been completed. If my patient, I would expect psychiatrist to call us back. I did speak with the nurse after I completed the consult. I did not follow up on the X-ray as it was the end of my shift and my week ends on Wednesdays at 5:30 p.m. and I had signed off on the patient."

Interview on 5/25/2016 at 1305 with Psychiatric Nurse Practitioner (NP #1) revealed "Standard of practice to order splint. I should not identify the problem. I should prescribe follow-up with attending physician who ordered the consult. The order to view X-ray and make recommendations was intended for medical provider. I don't recall a particular order, but if patient having pain, we (psychiatrist) would have followed up."

Interview on 05/25/2016 at 1310 with Behavioral Health Nurse (RN #1) revealed "I have been working here since June 22, 2015. Named staff member walked to X-ray with patient. I don't recall a splint or protective covering over patient's hand. I gave the TAO (triple antibiotic ointment) to the patient in a medicine cup to apply as needed. Provider for medical consult would normally writer orders as per plan written in progress notes. I would call or charge nurse would call if no orders were placed for plan. It sometimes takes a while for the consulting provider to place order in the system to match his progress note plan. If not familiar with how to splint, we would contact someone that was familiar with splinting procedure. When I asked about pain, he would just sling his hand in the air. When he did respond, he was usually cursing."

Interview on 05/26/2016 at 0940 with Behavioral Health Nurse (RN #2) revealed "I have been working her since April, 2015. He wouldn't let anyone look at it (hand), hand had little bit of blood on it. I normally call doctor and document orders. I don't recall any notes about a splint."

Review of the hospital's policy and procedure titled "Observation and Precautions", last revised 12/13/2013, revealed ". . . The Charge RN is responsible for assuring that all patient observations are completed and documented by a member of the nursing staff. . . . C. The assigned staff records the patient's location and behavior on the patient check sheet at the time the patient check is done. . . ."

3. Review of Behavioral Health 15 Minute Close Observation Checks Sheet revealed a block labeled "Time" with a block directly beneath "Time" labeled with the following time frames "0000-0300", "0300-0500", "0500-0700", "0700-0900", "0900-1100", "1100-1200", "1200-1300", "1300-1500", "1500-1700", "1700-1900", "1900-2100", "2100-0000". Further review revealed a second block labeled "RN Initials" with a blank (open) block located just beneath RN Initials. Review of 15 Minute Close Observation Checks Sheets for Hall A from 04/05/2016 through 04/19/2016 revealed no available documentation of a Registered Nurse's initials to verify 15 minute observation checks had been completed on 04/06/2016 for 0700-0900, 0900-1100, 1100-1200, 1200-1300, 1300-1500, 1500-1700, 1700-1900, 1900-2100, and 2100-0000, on 04/07/2016 for 1900-2100 and 2100-0000, on 04/08/2016 for 1500-1700 and 1700-1900, on 04/09/2016 for 0700-0900, 0900-1100, 1100-1200, 1200-1300, 1300-1500, 1500-1700 and 1700-1900, on 04/10/2016 for 0000-0300, 0300-0500, 0500-0700, 0700-0900, 0900-1100, 1100-1200,1200-1300, 1300-1500, 1500-1700 and 1700-1900, on 04/11/2016 for 1200-1300, 1300-1500, 1500-1700 and 1700-1900, on 04/12/2016 for 0700-0900, 0900-1100, 1100-1200, 1200-1300, 1300-1500, 1500-1700 and 1700-1900, on 04/13/2016 for 0700-0900, 0900-1100, 1100-1200, 1200-1300, 1300-1500, 1500-1700 and 1700-1900, on 04/14/2016 for 0000-0300, 0300-0500, 0500-0700, 0700-0900, 0900-1100, 1100-1200,1200-1300, 1300-1500, 1500-1700 and 1700-1900, on 04/15/2016 for 0700-0900, 0900-1100, on 04/16/2016 for 0700-0900, 0900-1100, 1100-1200,1200-1300, 1300-1500, 1500-1700 and 1700-1900, on 04/17/2016 for 0700-0900, 0900-1100, 1100-1200, 1200-1300, 1300-1500, 1500-1700, 1700-1900, 1900-2100 and 2100-0000, on 04/18/2016 for 0700-0900, 0900-1100, 1100-1200, 1200-1300, 1300-1500, 1500-1700 and 1700-1900, and on 04/19/2016 for 0700-0900, 0900-1100, 1100-1200, 1200-1300, 1300-1500, 1500-1700 and 1700-1900.

Interview on 05/26/2016 at 1015 with AS #2 revealed "The Registered Nurse should have documented initials as a sign of completion."

Interview on 05/26/2016 at 1110 with a Behavioral Health Technician (MHT #1) revealed, "I liked the previous form. Each person (patient) had their own sheet. This paper has nothing but names. Other sheet gave precautions - suicide, falls. All of it was on the sheet so I knew the person."

Interview on 05/26/2016 at 1030 with AS #4 revealed "These 15 Minute Close Observation forms are not the forms we approved for use in the past. We will be discussing at the next scheduled Behavorial Health (Hosptial Name) meeting."


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