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Based on review of policy and procedure, medical record review and staff interviews the nursing staff failed to evaluate nursing care as evidenced by failing to document patient safety observations every 15 minutes for 1 of 16 patients reviewed (Patient #1) and failing to document the effect of the prn medications for 1 of 6 patients sampled (Patient #1).

The findings include:

1. Review of the policy and procedure POLICY NO: CS61-Observation (Levels of Observation) (last review date 3/15) on 10/22/2015 revealed, "... All individuals in care are observed for safety a minimum of every 15 minute [sic] unless a more intensive level of observation is order [sic] by a physician. ..."

Review of Patient #1's (Pt #1) closed medical record on 10/20/2015 revealed that Pt #1 was involuntarily committed on 10/03/2015 with a diagnosis of depression (feeling of sadness and loss of interest), suicidal thoughts (thoughts about how to kill oneself), and experiencing auditory (hearing)/visual (seeing) hallucinations (a sensory experience of something that does not exist outside the mind) without a command. Review of a "Medical Consult Note" written on 10/6/2015 at 1100 revealed, "pt (Pt #1) at 2035 had 3 minute seizure patient has been increasingly confused, wandering, on the hallways, seeing things not there... Impressions/Recommendations...send patient (Pt #1) to hospital for further eval (evaluation)..." Review of "Nursing Flow Sheet/Progress Record" written on 10/06/2015 at 1330 revealed, Pt #1 was observed by nursing staff as being "delusional, paranoid, and wandering in and out of patient's rooms." Further review revealed the attending psychiatrist was notified, a medical consult was ordered and Pt #1 was taken to an acute care hospital ED (Hospital #2) for evaluation of her medical condition by EMS(emergency medical service). Review of "Precaution Record" documentation revealed every 15 minute observations documented on Pt #1 from admission through 10/05/2015 at 2345. Further review revealed no documentation of every 15 minute observations after 10/05/2015 at 2345.

Interview on 10/22/2015 at 1500 with the CNO(Chief Nursing Officer) revealed, visual confirmation of no documentation of every 15 minute observations after 10/05/2015 at 2345 on Pt #1, and that he " will go to .... (hospital #1) and attempt to find the missing observation sheets.

2. Review of the policy and procedure POLICY NO: NS69 A-Medication Administration (last review date 1/15) revealed "...Medication preparation, administration and documentation are carried out in a consistent and safe manner by the registered and practical nurses ... Documentation 1. Document the reason for administrating PRN (as needed) medication on the PRN Medication form. Enter the date, time, name of PRN medication, reason given, and your initials in space indicated. 2. Reassess patient and document effect of PRN medication. ..."

Review of Patient #1's (Pt #1) closed medical record on 10/20/2015 revealed that Pt #1 was involuntarily committed on 10/03/2015 with a diagnosis of depression (feeling of sadness and loss of interest), suicidal thoughts (thoughts about how to kill oneself), and experiencing auditory (hearing)/visual (seeing) hallucinations (a sensory experience of something that does not exist outside the mind) without a command. Review of medication administation record (MAR) on 10/20/2015 revealed that Vistaril (antianxiety medication) 25mg PO (by mouth) Q (every) 4 hours PRN (as needed) for anxiety(feeling worried or nervous) was administered on 10/05/2015 at 1345, 1700 and 2200, and again on 10/06/2015 at 0530 to Pt #1. Further review revealed that there was no documented reassessment of the effect of the PRN medication on the MAR.

Interview with RN #1 on 10/22/2015 at 1625 revealed visual confirmation that there is no documentation of effectiveness of PRN medication for Pt #1.

NC00111189