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Based on record review and interview the facility staff failed to develop a nursing care plan based on assessment of the patient's physiological and psychosocial factors in 1 of 1 patient with autism (Patient #1) in a total of 10 medical records reviewed.

Review of policy and procedure "Children's Hospital and Health System Patient Care Policy and Procedure" dated 8/09/2019 page 13 under Care Plans revealed "The nurse is responsible for: 1. Adding patient specific care plans based on the pateint's needs, nursing diagnoses, or medical diagnoses upon arrival to the unit and throughout the hospitalization...2. Selecting specific patient interventions and goals as individualized for the patient."

Patient 1's medical record revealed Patient #1 had come to the Emergency Department 8/19/19 at 11:52 PM after parents reported s/he had vomited "big chunks of blood". Patient #1 had a history of a tonsillectomy and adenoidectomy 8/13/2019 and autism, and was admitted for observation 8/20/2019 at 2:45 AM with the diagnosis of postoperative hemorrhage. Care plan included general daily care, inadequate fluid intake, pain, and patient/family involvement in plan of care. There is no individualization of Patient #1's plan of care for a patient with autism for impaired communication or coping.

On 10/08/2019 at 12:53 PM during an interview with Clinical Nurse Specialist (CNS) D, CNS D confirmed Patient #1's care plan was not individualized, there was no care plan for his/her autism stating, at the least, s/he would expect to see something "on coping."

Based on record review and interview, the facility staff failed to administer medication according their policy and procedures by failing to administer a medication for indication of use in 1 of 6 medications given (acetaminophen) to Patient #1 in a total of 10 medical records reviewed.

Findings include:

Review of policy "Children's Hospital and Health System Patient Cre Policy and Procedure" dated 7/01/2019 revealed III. Medication Orders A. Components of a Medication Order... 4. Indiction." Page 30 under Procedure revealed "Authorized HCP (health care providers) are required to verify the following prior to administering a medication... g. Right indication for use."

Patient #1's medical record was reviewed and revealed physician orders by ENT Resident G dated 8/20/19 at 1:48 AM for acetaminophen 325mg/10.15 ml solution 420 mg "Q6H" (every 6 hours) "Indications of use: Fever." Acetaminophen 10 ml was given 8/20/19 at 3:14 AM, 9:48 AM, 3:03 PM, 9:42 PM, 8/21/19 at 3:01 AM and 8:56 AM. Axillary temperature 8/20/19 at 10 AM was 99.1, otherwise documented temperatures were between 97 and 98.6 (normal). Nursing progress note dated 8/20/19 at 10:25 AM revealed "This RN (registered nurse) communicated would hold off on any additional oxycodone dose and administer Tylenol for any pain management. (MD updated)." There was no physician order to give Tylenol for pain in Patient #1's medical record.

During interview with Clinical Nurse Specialist (CNS) D on 10/08/2019 at 12:53 PM, CNS D confirmed there was no physician order to give acetaminophen for pain.