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Based on interview and record review the hospital failed to ensure the medical staff monitored and evaluated inpatient medical care and appropriately intervened when a significant change in a patient's condition occurred. The hospital failed to:

1) Assess and provide medical interventions for 1 of 1 patient (Patient #2) who was not eating and/or drinking and lost 9 pounds in three days and required emergent transfer to the medical hospital for dehydration and renal failure.

2) Current and previously discharged inpatients (Patient #1, #2, #8 and #10's) blood pressures were not monitored and/or reassessed when blood pressure readings were either elevated and/or low. No interventions and/or documentation addressed patient changes of condition occurred.


Cross refer to tag 0049

Based on interview and record review the Hospital failed to ensure the medical staff provided quality of care for inpatient Psychiatric patients. The medical staff failed to evaluate and/or assess patient care needs which included: 1) Follow-up on elevated and/or low blood pressures for 4 of 4 patients (Patients #1,#2, #8, #10). 2) Assess and intervene for 1 of 1 patient (Patient #2) who was not eating and/or drinking which resulted in an emergent transfer to the medical hospital on 02/25/12 where (Patient #2) was placed in ICU (Intensive Care Unit) for dehydration and required renal dialysis. This failure placed all patients at risk for developing dehydration and/or complications related to either elevated and/or low blood pressure.

Findings included:

1) (Patient #2's) nursing admission assessment dated 02/21/12 timed at 02:00 AM reflected, "Blood pressure 170/80...ADL's (activities of daily living) cannot walk about home, cannot bathe/dress, cannot dress prepare meals, take medications, do housework...cannot brush own teeth...poor hygiene, confused poor short/long term memory..."

The nursing daily flow sheet dated 02/21/12 completed by the technician and signed by RN (Registered Nurse) Staff #20 reflected, breakfast refused, lunch refused and supper percent eaten left blank. The intake, voided and dietary supplement section was left blank.

The precaution sheet-vital sign log dated 02/21/12 reflected (Patient #2's) weight was "242 pounds."

The physician progress note dated 02/22/12 reflected, "Refused to eat and drink yesterday...per family this is out of character for patient..." No documentation was found which indicated the physician addressed and/or intervened.

The nursing daily flow sheet dated 02/22/12 completed by the technician and signed by RN Staff #20 reflected, breakfast refused, lunch refused and supper percent eaten 50%. The intake, voided and dietary supplement section was left blank.

The progress notes-nursing notes dated 02/23/12 timed at 12:15 PM reflected, "Pt (patient) appears more alert today...however, she is still lethargic, slurred speech and disheveled...provide safe therapeutic environment while assessing mental/physical status..."

The nursing daily flow sheet dated 02/23/12 completed by the technician and signed by RN Staff #20 reflected, breakfast 20%, lunch 10% and supper refused. The intake, voided and dietary supplement section was left blank.

The nursing daily flow sheet dated 02/24/12 completed by the technician and signed by RN Staff #16 reflected, breakfast 10%, lunch refused and supper left blank. The intake, voided and dietary supplement section was left blank and fluids were hand written in under the breakfast and the lunch section.

The 02/24/12 precaution sheet/vital sign log reflected, "08:00 AM B/P (blood pressure) 148/81...12:00 Noon B/P 85/48...18:00 PM B/P 84/59...weight 233.08 pounds..." (Patient #2) lost 9 pounds in three days. No documentation was found which indicated (Patient #2's) low blood pressure was addressed.

The nursing daily flow sheet dated 02/25/12 completed by the technician and signed by RN Staff #16 reflected, breakfast 0%, lunch 5% and supper 5%. The intake, voided and dietary supplement section was left blank.

The physician orders dated 02/25/12 timed at 14:40 PM reflected, "Push fluids, monitor for possible dehydration...at 20:29 PM transfer to the ER (emergency room) for eval (evaluation)..." No documentation was found which indicated fluids were pushed and/or ensure was provided for (Patient #2).

The progress notes-nursing notes dated 02/25/12 timed at 17:50 PM reflected, "Patient appears drowsy, won't open eyes up...poor appetite, poor po (by mouth) fluid intake...needs assistance with ADL's..provide a safe and therapeutic environment...at 20:50 PM the note continued...tech (technician) noted that client was cool to touch, unresponsive and unable to obtain pulse...B/P...respirations 40 and erratic...apical is weak...40 a minute...unresponsive to verbal/physical stimuli...unable to palpate B/P or obtain with stethoscope...oxygen saturation 81% and client is cold, color is white and pasty...orders received to transfer to ER (emergency room) for evaluation...client's family called regarding transfer and change in condition..."

(Patient #2's) medical record from Hospital B dated 02/25/12 timed at 21:06 PM reflected, "Lethargy...BUN (blood urea nitrogen) 90...creatinine 6.5...dehydration...volume depletion...acute renal failure...hypotension...at 21:30 PM B/P 95/52...22:22 PM B/P 70/48...placed in Trendelenburg position and increased fluids bolus...at 01:00 AM B/P 88/53..."

Hospital B's physician consult dated 02/28/12 reflected, "In the Behavioral Health, the patient was not eating and drinking and hence she was noted to be in an extremely obtunded state when she came into the emergency room...upon arrival her blood pressure was 83/46...BUN of 90 and creatinine of 6.5...the patient has had one treatment of renal dialysis..."

On 07/19/12 at approximately 09:40 AM Staff #6 was interviewed. Staff #6 reviewed (Patient #2's) medical record. Staff #6 stated no nutritional screen was initiated on (Patient #2). Staff #6 stated the RN's are supposed to review the vital sign flow sheet and sign it. Staff #6 said the nursing staff should have addressed (Patient #2) not eating and/or drinking and provided interventions. Staff #6 said no interventions were provided for (Patient #2) when her blood pressure initially dropped.

On 07/19/12 at approximately 12:15 PM Staff #11 was interviewed. Staff #11 was asked to review (Patient #2's) medical record. Staff #11 said she saw (Patient #2) on 02/25/12 and informed the staff to push fluids and give ensure. Staff #11 said the nursing staff were not good about documenting vital signs and the information needed to care for the patient. Staff #11 stated the nursing staff does not always document and/or communicate important information so it can be followed-up on.

2) On 07/18/12 at approximately 03:55 PM a tour of the SCU (Stabilization Care Unit) was toured with Staff #3. The surveyor reviewed the technician's patient vital sign records. (Patient #8's) blood pressure reading at 06:00 AM on 07/17/12 was 98/56. The record did not indicate a second blood pressure was taken. Staff #6 was asked to review the vital sign log and the nursing note for 07/17/12. Staff #3 verified (Patient #8's) low blood pressure reading was not addressed and a recheck was not completed by Staff #17.

(Patient #8's) history and physical dated 07/11/12 reflected, "66 year old...multiple admissions here for bipolar with hallucinations, suicidal ideation and homicidal ideation...past medical history...hypertension, COPD (Chronic Obstructive Pulmonary Disease)..."

(Patient #8's) vital sign log dated 07/17/12 reflected, (Patient #8's) blood pressure was 98/56..." No further documentation was found which indicated (Patient #8's) blood pressure was re-checked and/or addressed by the RN Staff #17 and/or the physician was notified.

The interdisciplinary progress notes dated 07/17/12 reflected no documentation by Staff #17 which indicated (Patient #8's) low blood pressure reading was addressed.

The medical staff Bylaws dated 03/13/09 reflected, "Each department or service shall monitor and evaluate medical care on a retrospective, concurrent and prospective basis in all major clinical activities of the department or service...the monitoring and evaluation must at least include: the identification and collection of information about important aspects of patient care...identify important problems in patient care..."

3) (Patient #1's) "Medical Stability Attestation" document dated 02/03/12 and the "In-Patient Physician Orders" dated 02/03/12 reflected admitting diagnoses including Hypertension and Stroke. The patient's blood pressure was 195/117 according to the vital sign log dated 02/10/12 at 6:00 AM; an additional blood pressure reading of 193/117 was documented on 02/10/12 at 09:20 AM. No further blood pressure was documented.

The interdisciplinary progress notes dated 02/10/12 at 09:00 AM reflected that "(Patient #1) was still not feeling well..." The "Nursing Daily Flow Sheet" dated 02/10/12 reflected (Patient #1) was on medical concern precautions.

On 02/15/12 at 06:00 AM (Patient #1's) vital sign log reflected a blood pressure reading of 206/117. The only 02/15/12 entry on the "Progressive Nursing Notes" at 5:00 PM did not indicate any blood pressure concerns. The "Physician Daily Progress Notes" dated 02/15/12 at 10:35 AM did not mention (Patient #1's) blood pressure reading.

4) (Patient #10) was admitted on 07/10/12 with an admitting diagnoses including Major Depressive Disorder. The patient reported she had not eaten in 10 days. The "Psychiatric Evaluation" dated 07/11/12 reflected a "long history of depression and anorexia." The "History and Physical Consultation" dated 07/11/12 reflected an admission blood pressure of 100/75.

The "Vital Sign Log" dated 07/11/12 at 6:00 AM reflected (Patient #10) had a blood pressure of 106/75. Further blood pressure readings were 90/65 at 2:00 PM and 84/54 at 10:00 PM. The following day, on 07/12/12 (Patient #10's) blood pressure was 86/51 at 6:00 AM, 87/51 at 6:00 PM, and 81/51 at 10:00 PM. Eight hours later, on 07/13/12 at 6:00 AM, (Patient #10) had a blood pressure of 84/55. No further blood pressure readings were documented.

During an interview on 07/18/12 around 3:30 PM Staff #3 stated she could not find any additional blood pressure readings on 07/13/12 for (Patient #10). When requested by the surveyor to provide additional documentation, Staff #3 stated at that time, "There is no other blood pressure."

Based on interview and record review the hospital failed to ensure the physical and medical needs of both discharged and/or current inpatients was provided. The hospital failed to ensure a safe environment was provided for patients who demonstrated a change in their medical condition as evidenced by the following:

1) Assessment and medical intervention was not provided for 1 of 1 patient (Patient #2) who was not eating and/or drinking and lost 9 pounds in three days. (Patient #2) required emergent transfer to the medical hospital for dehydration, low blood pressure and renal failure.

2) Current and previously discharged inpatient (Patient #1, #2, #8 and #10's) blood pressures were not monitored and/or reassessed when blood pressure readings were either elevated and/or low. No interventions and/or documentation addressed a patient change of condition occurred nor what care was provided for the 4 patients.

3) Equipment was not provided for 1 of 1 patient (Patient #1) with sleep apnea. (Patient #1) slept an average of 4.9 hours per night, missed the initial four days of therapy, and was sleepy during the day.

These failures placed all patients at risk for developing dehydration and/or complications related to either elevated and/or low blood pressure, and complications related to inadequate sleep.


Cross refer to Tag 0144

Based on interview and record review the Hospital failed to ensure 4 of 4 patient's (Patient #1, #2, #8 and #10) received medical care in a safe setting and patient care needs were evaluated and/or assessed which included: 1) Follow-up on elevated and/or low blood pressures for 4 of 4 patients (Patients #1, #2, #8 and #10). 2) Assess and provide nursing interventions for 1 of 1 patient (Patient #2) who was not eating and/or drinking and lost 9 pounds in 3 days which resulted in an emergent transfer to the medical hospital 02/25/12 where (Patient #2) was placed in ICU (Intensive Care Unit) for dehydration and required renal dialysis. 3) Provide 1 of 1 patient (Patient #1) with equipment needed for sleep apnea. (Patient #1) slept an average of 4.9 hours per night, missed the initial four days of therapy, and was sleepy during the day.

This failure placed all patients at risk for developing dehydration and/or complications related to either elevated and/or low blood pressure, and complications related to inadequate sleep.

Findings included:

1) (Patient #2's) nursing admission assessment dated 02/21/12 timed at 02:00 AM reflected, "Blood pressure 170/80...ADL's (activities of daily living) cannot walk about home, cannot bathe/dress, cannot dress prepare meals, take medications, do housework...cannot brush own teeth...poor hygiene, confused poor short/long term memory..."

The nursing daily flow sheet dated 02/21/12 completed by the technician and signed by RN (Registered Nurse) Staff #20 reflected, breakfast refused, lunch refused and supper percent eaten left blank. The intake, voided and dietary supplement section was left blank.

The precaution sheet-vital sign log dated 02/21/12 reflected (Patient #2's) weight was "242 pounds."

The physician progress note dated 02/22/12 reflected, "Refused to eat and drink yesterday...per family this is out of character for patient..." No documentation was found which indicated the physician addressed and/or intervened.

The nursing daily flow sheet dated 02/22/12 completed by the technician and signed by RN Staff #20 reflected, breakfast refused, lunch refused and supper percent eaten 50%. The intake, voided and dietary supplement section was left blank.

The progress notes-nursing notes dated 02/23/12 timed at 12:15 PM reflected, "Pt (patient)
appears more alert today...however, she is still lethargic, slurred speech and disheveled...provide safe therapeutic environment while assessing mental/physical status..."

The nursing daily flow sheet dated 02/23/12 completed by the technician and signed by RN Staff #20 reflected, breakfast 20%, lunch 10% and supper refused. The intake, voided and dietary supplement section was left blank.

The nursing daily flow sheet dated 02/24/12 completed by the technician and signed by RN Staff #16 reflected, breakfast 10%, lunch refused and suppler left blank. The intake, voided and dietary supplement section was left and fluids were hand written in under the breakfast and the lunch section.

The 02/24/12 precaution sheet/vital sign log reflected, "08:00 AM B/P (blood pressure) 148/81...12:00 Noon B/P 85/48...18:00 PM B/P 84/59...weight 233.08 pounds..." (Patient #2) lost 9 pounds in three days. No documentation was found which indicated (Patient #2's) low blood pressure was addressed.

The nursing daily flow sheet dated 02/25/12 completed by the technician and signed by RN Staff #16 reflected, breakfast 0%, lunch 5% and supper 5%. The intake, voided and dietary supplement section was left blank.

The physician orders dated 02/25/12 timed at 14:40 PM reflected, "Push fluids, monitor for possible dehydration...at 20:29 PM transfer to the ER (emergency room) for eval (evaluation)..." No documentation was found which indicated fluids were pushed and/or ensure was provided for (Patient #2).

The progress notes-nursing notes dated 02/25/12 timed at 17:50 PM reflected, "Patient appears drowsy, won't open eyes up...poor appetite, poor po (by mouth) fluid intake...needs assistance with ADL's..provide a safe and therapeutic environment...at 20:50 PM the note continued...tech (technician) noted that client was cool to touch, unresponsive and unable to obtain pulse...B/P...respirations 40 and erratic...apical is weak...40 a minute...unresponsive to verbal/physical stimuli...unable to palpate B/P or obtain with stethoscope...oxygen saturation 81% and client is cold, color is white and pasty...orders received to transfer to ER (emergency room) for evaluation..."

(Patient #2's) medical record from Hospital B dated 02/25/12 timed at 21:06 PM reflected, "Lethargy...BUN (blood urea nitrogen) 90...creatinine 6.5...dehydration...volume depletion...acute renal failure...hypotension...at 21:30 PM B/P 95/52...22:22 PM B/P 70/48...placed in Trendelenburg position and increased fluids bolus...at 01:00 AM B/P 88/53..."

Hospital B's physician consult dated 02/28/12 reflected, "In the Behavioral Health, the patient was not eating and drinking and hence she was noted to be in an extremely obtunded state when she came into the emergency room...upon arrival her blood pressure was 83/46...BUN of 90 and creatinine of 6.5...the patient has had one treatment of renal dialysis..."

On 07/19/12 at approximately 09:40 AM Staff #6 was interviewed. Staff #6 reviewed (Patient #2's) medical record. Staff #6 stated no nutritional screen was initiated on (Patient #2). Staff #6 stated the RN's are supposed to review the vital sign flow sheet and sign it. Staff #6 said the nursing staff should have addressed (Patient #2) not eating and/or drinking and provided interventions. Staff #6 said the nurse did not intervene when (Patient #2's) blood pressure initially dropped.

The Education Department nursing meeting dated 04/27/12 reflected, "Patient weights are to be done on admission and twice a week unless otherwise ordered...intake and output..." The 05/31/12 nursing meeting reflected, "Post fall debriefing, document reviews..." The 06/28/12 nursing meeting reflected, "Nursing documentation (enhanced description of symptoms present..." The nursing meeting dated 06/28/12-07/13/12 reflected, "Dietary consult education..." No documentation was found which indicated assessment and follow-up on patient changes was conducted during the above training.

2) On 07/18/12 at approximately 03:55 PM a tour of the SCU (Stabilization Care Unit) was toured with Staff #3. The surveyor reviewed the technician's patient vital sign records. (Patient #8's) blood pressure reading at 06:00 AM on 07/17/12 was 98/56. The record did not indicate a second blood pressure was taken. Staff #6 was asked to review the vital sign log and the nursing note for 07/17/12. Staff #3 verified (Patient #8's) low blood pressure reading was not addressed and a recheck was not completed by Staff #17.

(Patient #8's) history and physical dated 07/11/12 reflected, "66 year old...multiple admissions here for bipolar with hallucinations, suicidal ideation and homicidal ideation...past medical history...hypertension, COPD (Chronic Obstructive Pulmonary Disease)..."

(Patient #8's) vital sign log dated 07/17/12 reflected, (Patient #8's) blood pressure was 98/56..." No further documentation was found which indicated (Patient #8's) blood pressure was re-checked and/or addressed by the RN Staff #17.

The interdisciplinary progress notes dated 07/17/12 reflected no documentation by Staff #17 which indicated (Patient #8's) low blood pressure reading was addressed.

3) (Patient #10) was admitted on 07/10/12 with an admitting diagnoses including Major Depressive Disorder. The patient reported she had not eaten in 10 days. The "Psychiatric Evaluation" dated 07/11/12 reflected a "long history of depression and anorexia." The "History and Physical Consultation" dated 07/11/12 reflected an admission blood pressure of 100/75.

The "Vital Sign Log" dated 07/11/12 at 6:00 AM reflected (Patient #10) had a blood pressure of 106/75. Further blood pressure readings were 90/65 at 2:00 PM and 84/54 at 10:00 PM. The following day, on 07/12/12 (Patient #10's) blood pressure was 86/51 at 6:00 AM, 87/51 at 6:00 PM, and 81/51 at 10:00 PM. Eight hours later, on 07/13/12 at 6:00 AM, (Patient #10) had a blood pressure of 84/55. No further blood pressure readings were documented.

During an interview on 07/18/12 around 3:30 PM Staff #3 stated she could not find any additional blood pressure readings on 07/13/12 for (Patient #10). When requested by the surveyor to provide additional documentation Staff #3 stated at that time, "There is no other blood pressure."

4) ( Patient #1's) "Medical Stability Attestation" document dated 02/03/12 and the "In-Patient Physician Orders" dated 02/03/12 reflected admitting diagnoses included Hypertension and Stroke.

(Patient #1's) blood pressure was 195/117 according to the vital sign log dated 02/10/12 at 6:00 AM; an additional blood pressure reading of 193/117 was documented on 02/10/12 at 09:20 AM. No further blood pressure was documented. The interdisciplinary progress notes dated 02/10/12 at 09:00 AM reflected that "(Patient #1) was still not feeling well..." The "Nursing Daily Flow Sheet" dated 02/10/12 reflected (Patient #1) was on medical concern precautions.

On 02/15/12 at 06:00 AM (Patient #1's) vital sign log reflected a blood pressure reading of 206/117. The only 02/15/12 entry on the "Progressive Nursing Notes" at 5:00 PM did not indicate any blood pressure concerns. The "Physician Daily Progress Notes" dated 02/15/12 at 10:35 AM did not mention (Patient #1's) blood pressure reading.

(Patient #1's) psychiatric evaluation and nursing admission assessment, both dated 02/03/12 included a medical history of Asthma, Chronic Obstructive Pulmonary Disease, and Obstructive Sleep Apnea. The "Comprehensive Admission Screening" dated 02/03/12 reflected Patient #1 used a CPAP machine [to provide continuations positive airway pressure] and oxygen therapy. The document reflected (Patient #1) had been disabled with Congestive Heart Failure since 1996.

According to the "Group Notes" (Patient #1) did not attend group therapy on 02/04/12, 02/05/12, 02/06/12, and 02/07/12; on 02/13/12 (Patient #1) excused herself from the group with complaints she could not breathe. Then "Daily Nursing Flow Sheet" night shift documentation between 02/03/12 and 02/16/12 reflected (Patient #1) slept an average of 4.9 hours per night.

During an interview on 07/18/12 at 2:10 PM Staff #2 stated she could not find documentation that (Patient #1) CPAP was used.

The policy entitled, "Delivery Model" with a current effective date of 12/11 reflected, "The Modified Team Nursing Model (MTN)...supports the goal of providing holistic nursing care meeting the psychosocial, physical, and spiritual needs of a patient across the lifespan using the nursing process...the RN in Charge...ensures patient assessments are completed...collaborates with health care team members to ensure patient/family needs are met...nurse aide member...provides direct patient care under the supervision of the RN to include...data collection and documentation, to include height, weight, I/O (intake and output), vital signs...nutritional activities..."

Based on interview and record review the hospital failed to ensure nursing services was adequately being supervised. Nursing services failed to provide the following:

1) Assess and provide medical interventions for 1 of 1 patient (Patient #2) who was not eating and/or drinking and lost 9 pounds in three days and required emergent transfer to the medical hospital for dehydration and renal failure.

2) Current and previously discharged inpatient (Patient #1, #2, #8 and #10's) blood pressures were not monitored and/or reassessed when blood pressure readings were either elevated and/or low. No interventions and/or documentation addressed a patient change of condition occurred.

3) The hospital failed to provide adequate number of nursing personnel to provide assistance with ADL's (activities of daily living) for 2 of 2 patients (Patient #9 and #10). Patient's were not bathed and/or left with soiled clothes on.

Cross refer to Tag 0392 and 0395

The hospital failed to provide adequate number of nursing personnel to provide care to patients as needed to provided assistance with ADLs for 2 of 2 patients (Patient #9 and #10). (Patient #9) did not receive a bath for three days. (Patient #10) wore badly stained clothes on the unit.

Findings included:

1) Observations on 07/18/12 at 4:30 PM on the hospital's Acute Care Unit reflected, (Patient #9) was sitting in a wheel chair with an attached lap tray. The unit was malodorous. (Patient #9) wore a stained sweat shirt and complained she did not have a bath "in three days." Staff #8 verified (Patient's #9's) bath was three days ago.

The Interdisciplinary Progress Notes dated 07/09/12 at 10:00 PM and 07/09/12 at 10:50 AM reflected (Patient #9) was "dependent for ADLs." On 07/09/12 at 10:50 AM the notes reflected Patient #9's comment, "I am worried about my clothes."

2) (Patient #10) was observed on 07/20/12 at 9:03 AM curled up on the sofa next to the entrance way. The patient was disheveled, dressed in a plaid jacket with badly stained sleeves and front.

Observations on 07/20/12 at 9:05 AM on the hospitals Progressive Care Unit reflected a strong urine smell in the hallway across from the patient laundry room. A grey bucket with two towels was left underneath two chairs in the hallway.

On 07/20/12 at 9:10 AM Staff #3 agreed that there was an odor and verbalized the intention to call housekeeping.

During an interview on 07/19/12 at 3:45 PM Staff #12 stated patients did not get bathed or shaved due to the lack of staff. Staff #12 stated patients did not get their personal clothes washed and had to wear paper scrubs during visitation nor did patients get to go outside due to staffing issues.

On 07/19/12 at 5 PM Staff #14 stated that providing showers for patients was "extremely difficult" due to staffing issues. Before visitation, staff would "wipe them [the patients] down and spray some scents on them to make them smell good." Mental Health Technicians (MHTs) were taken off the unit "daily" to accommodate visits to outside groups or physician visits.

During an interview on 07/20/12 at 10:30 AM Staff #15 stated that nurses were left with up to 32 patients once the MHT "gets pulled..." Staff #15 stated "ADLs [activities of daily living] don't get done and they don't offer snacks."

On 07/20/12 at 11:41 AM an unidentified male patient was observed sitting at a table in front of a lunch tray in the otherwise empty day room. No staff assisted the patient. Staff #18 was observed in the closed door consultation room speaking with the physician. Upon surveyor inquiry, Staff #18 entered the day room and explained he gave report to the physicians during their unit visits as part of his job duties.

The policy entitled, "Delivery Model" with a current effective date of 12/11 reflected, "The Modified Team Nursing Model provides...comprehensive, compassionate and individualized nursing care in a manner that maintains the dignity, rights...of patients...it supports the goal of providing holistic nursing care meeting the psychosocial, physical...needs of the patient..."

Based on interview and record review the Hospital failed to ensure 4 of 4 RN's (Registered Nurses) (RN #15, #16, #17 and #20) evaluated and/or assessed patient care needs which included: 1) Follow-up on elevated and/or low blood pressures for 3 of 3 patients (Patient #2, #8, and #10). 2) Assess and provide nursing interventions for 1 of 1 patient (Patient #2) who was not eating and/or drinking and lost 9 pounds in 3 days. Patient #2's blood pressure dropped and resulted in an emergent transfer to the medical hospital 02/25/12. (Patient #2) was placed in ICU (Intensive Care Unit) for dehydration and required renal dialysis. This failure placed all patients at risk for developing dehydration and/or complications related to either elevated and/or low blood pressure.

Findings included:

1) (Patient #2's) nursing admission assessment dated 02/21/12 timed at 02:00 AM reflected, "Blood pressure 170/80...ADL's (activities of daily living) cannot walk about home, cannot bathe/dress, cannot dress prepare meals, take medications, do housework...cannot brush own teeth...poor hygiene, confused poor short/long term memory..."

The nursing daily flow sheet dated 02/21/12 completed by the technician and signed by RN (Registered Nurse) Staff #20 reflected, breakfast refused, lunch refused and supper percent eaten left blank. The intake, voided and dietary supplement section was left blank.

The precaution sheet-vital sign log dated 02/21/12 reflected (Patient #2's) weight was "242 pounds."

The physician progress note dated 02/22/12 reflected, "Refused to eat and drink yesterday...per family this is out of character for patient..."

The nursing daily flow sheet dated 02/22/12 completed by the technician and signed by RN Staff #20 reflected, breakfast refused, lunch refused and supper percent eaten 50%. The intake, voided and dietary supplement section was left blank.

The progress notes-nursing notes dated 02/23/12 timed at 12:15 PM reflected, "Pt (patient) appears more alert today...however, she is still lethargic, slurred speech and disheveled...provide safe therapeutic environment while assessing mental/physical status..."

The nursing daily flow sheet dated 02/23/12 completed by the technician and signed by RN Staff #20 reflected, breakfast 20%, lunch 10% and supper refused. The intake, voided and dietary supplement section was left blank.

The nursing daily flow sheet dated 02/24/12 completed by the technician and signed by RN Staff #16 reflected, breakfast 10%, lunch refused and supper left blank. The intake, voided and dietary supplement section was left blank and fluids were hand written in under the breakfast and the lunch section.

The 02/24/12 precaution sheet/vital sign log reflected, "08:00 AM B/P (blood pressure) 148/81...12:00 Noon B/P 85/48...18:00 PM B/P 84/59...weight 233.08 pounds..." (Patient #2) lost 9 pounds in three days. No documentation was found which indicated (Patient #2's) low blood pressure was addressed.

The nursing daily flow sheet dated 02/25/12 completed by the technician and signed by RN Staff #16 reflected, breakfast 0%, lunch 5% and supper 5%. The intake, voided and dietary supplement section was left blank.

The physician orders dated 02/25/12 timed at 14:40 PM reflected, "Push fluids, monitor for possible dehydration...at 20:29 PM transfer to the ER (emergency room) for eval (evaluation)..."

The progress notes-nursing notes dated 02/25/12 timed at 17:50 PM reflected, "Patient appears drowsy, won't open eyes up...poor appetite, poor po (by mouth) fluid intake...needs assistance with ADL's..provide a safe and therapeutic environment...at 20:50 PM the note continued...tech (technician) noted that client was cool to touch, unresponsive and unable to obtain pulse...B/P...respirations 40 and erratic...apical is weak...40 a minute...unresponsive to verbal/physical stimuli...unable to palpate B/P or obtain with stethoscope...oxygen saturation 81% and client is cold, color is white and pasty...orders received to transfer to ER (emergency room) for evaluation..."

(Patient #2's) medical record from Hospital B dated 02/25/12 timed at 21:06 PM reflected, "Lethargy...BUN (blood urea nitrogen) 90...creatinine 6.5...dehydration...volume depletion...acute renal failure...hypotension...at 21:30 PM B/P 95/52...22:22 PM B/P 70/48...placed in Trendelenburg position and increased fluids bolus...at 01:00 AM B/P 88/53..."

Hospital B's physician consult dated 02/28/12 reflected, "In the Behavioral Health, the patient was not eating and drinking and hence she was noted to be in an extremely obtunded state when she came into the emergency room...upon arrival her blood pressure was 83/46...BUN of 90 and creatinine of 6.5...the patient has had one treatment of renal dialysis..."

On 07/19/12 at approximately 09:40 AM Staff #6 was interviewed. Staff #6 reviewed (Patient #2's) medical record. Staff #6 stated no nutritional screen was initiated on (Patient #2). Staff #6 stated the RN's are supposed to review the vital sign flow sheet and sign it. Staff #6 said the nursing staff should have addressed (Patient #2) not eating and/or drinking and provided interventions. Staff #6 said the nurse did not intervene when (Patient #2's) blood pressure initially dropped.

On 07/19/12 at approximately 12:15 PM Staff #11 was interviewed. Staff #11 was asked to review (Patient #2's) medical record. Staff #11 said she saw (Patient #2) on 02/25/12 and informed the staff to push fluids and give ensure. Staff #11 said the nursing staff were not good about documenting vital signs and the information needed to care for the patient. Staff #11 stated the nursing staff does not always document important information so it can be followed-up on.

The Education Department nursing meeting dated 04/27/12 reflected, "Patient weights are to be done on admission and twice a week unless otherwise ordered...intake and output..." The 05/31/12 nursing meeting reflected, "Post fall debriefing, document reviews..." The 06/28/12 nursing meeting reflected, "Nursing documentation (enhanced description of symptoms present..." The nursing meeting dated 06/28/12-07/13/12 reflected, "Dietary consult education..." No documentation was found which indicated assessment and follow-up on patient changes was conducted during the above training.

2) On 07/18/12 at approximately 03:55 PM a tour of the SCU (Stabilization Care Unit) was toured with Staff #3. The surveyor reviewed the technician's patient vital sign records. (Patient #8's) blood pressure reading at 06:00 on 07/17/12 was 98/56. The record did not indicate a second blood pressure was taken. Staff #6 was asked to review the vital sign log and the nursing note for 07/17/12. Staff #3 verified (Patient #8's) low blood pressure reading was not addressed and a recheck was not completed by Staff #17.

(Patient #8's) history and physical dated 07/11/12 reflected, "66 year old...multiple admissions here for bipolar with hallucinations, suicidal ideation and homicidal ideation...past medical history...hypertension, COPD (Chronic Obstructive Pulmonary Disease)..."

(Patient #8's) vital sign log dated 07/17/12 reflected, (Patient #8's) blood pressure was 98/56..." No further documentation was found which indicated (Patient #8's) blood pressure was re-checked and/or addressed by RN Staff #17.

The interdisciplinary progress notes dated 07/17/12 reflected no documentation by Staff #17 which indicated (Patient #8's) low blood pressure reading was addressed.

3) (Patient #10) was admitted on 07/10/12 with an admitting diagnoses including Major Depressive Disorder. The patient reported she had not eaten in 10 days. The "Psychiatric Evaluation" dated 07/11/12 reflected a "long history of depression and anorexia." The "History and Physical Consultation" dated 07/11/12 reflected an admission blood pressure of 100/75.

The "Vital Sign Log" dated 07/11/12 at 6:00 AM reflected (Patient #10) had a blood pressure of 106/75. Further blood pressure readings were 90/65 at 2:00 PM and 84/54 at 10:00 PM. The following day, on 07/12/12 (Patient #10's) blood pressure was 86/51 at 6:00 AM, 87/51 at 6:00 PM, and 81/51 at 10:00 PM. Eight hours later, on 07/13/12 at 6:00 AM, (Patient #10) had a blood pressure of 84/55. No further blood pressure readings were documented.

During an interview on 07/18/12 around 3:30 PM Staff #3 stated she could not find any additional blood pressure readings on 07/13/12 for (Patient #10). When requested by the surveyor to provide additional documentation, Staff #3 stated at that time, "There is no other blood pressure."

The policy entitled, "Delivery Model" with a current effective date of 12/11 reflected, "The Modified Team Nursing Model (MTN)...supports the goal of providing holistic nursing care meeting the psychosocial, physical, and spiritual needs of a patient across the lifespan using the nursing process...the RN in Charge...ensures patient assessments are completed...collaborates with health care team members to ensure patient/family needs are met...nurse aide member...provides direct patient care under the supervision of the RN to include...data collection and documentation, to include height, weight, I/O (intake and output), vital signs...nutritional activities..."