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Based on document review and interviews, it was determined that for 2 of 3 (Pt #1 and 7) patients requiring safety monitoring, the Hospital failed to ensure the patients' safety. The cumulative effect of this systemic practice resulted in the Hospital's inability to adequately protect the patients' rights. Therefore, the Hospital failed to comply with the Condition of Patients Rights.

1. The Hospital failed to ensure the patient that was restrained did not commit self harm. See deficiency at A 144A.

2. The Hospital failed to ensure patients were monitored for safety as required. See deficiency at A 144B.

Based on document review and interview, it was determined that in 3 of 3 (Pt #1, 7, and 8) clinical records reviewed of patients that were restrained, the Hospital failed to ensure the person of choice was notified of the restriction of rights based on restraint application.

Findings include:

1. Hospital policy entitled "Patient Care Services Utilization of Human Restraint," (revised 2/10) required, "Care of the Patient in Physical Restraints: 12. Whenever restraint and/or seclusion are used, the recipient shall be advised of his/her right to have any person of his/her choosing...notified of the event."

2. The clinical record of Pt #1 was reviewed on 4/9/13 at approximately 1:30 PM. Pt #1 was a 54 year old male admitted on 3/17/13 with diagnoses of Aggressive Behavior, Severe Hyponatremia, Suicide Attempt, and History of Schizophrenia. Pt #1's clinical record contained documentation that Pt #1 was placed in 4-point leather restraints on 3/20/13 at 5:00 AM, 9:00 AM, 1:00 PM, 5:00 PM, 8:30 PM without Notification of Restriction of Rights when applied at 9:00 AM. On 3/21/13, Pt #1 was again placed in 4-point leather restraints at 2:00 AM, 6:00 AM, 10:00 AM, 2:00 PM, and 6:00 PM without Notification of Restriction of Rights when applied at 6:00 AM. On 3/24/13, Pt #1 was again placed in 4-point leather restraints at 7:00 AM, 11:00 AM, 3:00 PM, 7:00 PM and 11:00 PM without Notification of Restriction of Rights at the times of application. Again on 3/25/13, Pt #1 was placed in 4-point leather restraints 3/25/13 at 3:00 AM and 7:00 AM without Notification of Restriction of Rights at the times of application.

3. The clinical record of Pt #7 was reviewed on 4/10/13 at approximately 1:30 PM. Pt #7 was a 61 year old female admitted on 4/1/13 with a diagnosis of Acute Respiratory Failure. Clinical documentation included that Pt #7 was in soft wrist and ankle restraints from 4/1/13 to 4/8/13 while on ventilator support. The clinical record contained Notification of Restriction of Rights dated 4/5/13 that failed to include the reason for restriction as well as who was to be notified.

4. The clinical record of Pt #8 was reviewed on 4/10/13 at approximately 1:30 PM. Pt #8 was a 69 year old male admitted on 4/9/13 with diagnoses of Hospital Acquired Pneumonia and Congestive Heart Failure Exacerbation. The clinical record of Pt #8 contained documentation that Pt #8 was restrained with 4-point leather restraints on 4/9/13. The clinical record contained a signed Notification of Restriction of Rights dated 4/9/13 that lacked the reason Pt #8 had rights restricted.

5. During interviews on 4/9/13 at approximately 1:30 PM and 4/10/13 at approximately 1:45 PM, the Vice President of Nursing Services verified the findings.

A. Based on document review and interviews, it was determined that in 1 of 3 (Pt #1) patients that were restrained, the Hospital failed to ensure the patient did not commit self harm.

Findings include:

1. Hospital policy entitled, "Patient Care Services Utilization of Human Restraints," (revised 2/10) required, "Policy: It is the policy of Saint Bernard Hospital that physical restraint shall be employed only in an emergency as a therapeutic measure to prevent a recipient from causing physical harm to himself/herself..."

2. The clinical record of Pt. #1 was reviewed on 4/9/13. Pt. #1 was a 54 year old male admitted on 3/17/13 to the Telemetry Unit with a Diagnosis of Severe Hyponatremia, Aggressive Behavior, Suicide Attempt, and history of Schizophrenia. Nursing documentation dated 3/20/13 at 12:16 AM indicated that, "Patient is with sitter 1:1 at bedside. Patient was placed in soft limb restraints on both arms". At 1:10 AM on 3/20/13 nursing documentation indicated, "Patient seen on bed fully awake, aggressive behavior still noted. Patient is with soft limb restraint on both arms with sitter 1:1 at bedside. His scrotal skin is torn apart, patient intentionally torn his scrotal sac apart...Readjusted restraint at this time. Seen by Dr. (house physician). "

3. On April 10, 2013 at approximately 8:10 AM, the Med-Tech Sitter, E#2 was interviewed. E #2 stated that she was "the sitter" the night the patient (Pt. #1) scratched his scrotum. E# 2 stated the patient (Pt. #1) needed constant redirection and was constantly removing gown, and trying to leave his room naked." E #2 also stated that she remembered calling the patient's (Pt #1) nurse because the patient was getting restless and was talking to himself. The nurse on duty called Security, applied soft wrist restraints, and the nurse gave patient some type of shot. E #2 stated that she remembered giving the patient (Pt #1) some water and the water drooling down of the side of his face, so she wiped his face and then she turned her back to wash her hands and when she turned back around, that is when she saw the patient grabbing his scrotal area with both hands while Pt #1 was still in soft restraints. E #2 stated that the patient (Pt #1) lifted his hips and was able to reach his hands into his groin and lacerate his scrotum.

4. On April 10, 2013 at approximately 8:30 AM, the Registered Nurse (E #3) on duty at the time of Pt #1's injury, was interviewed. E #3 stated that she was notified by E #2 that the patient (Pt. #1) was getting restless, removing his gown and wants to get out his room naked. E #2 stated when she assessed the patient (Pt. #1), the patient was restless and his blood pressure was elevated. E # 3 stated she called the house physician and received an order for 10 mg of Hydralazine (blood pressure medicine) intramuscularly (IM) and Haldol 5 mg IM and restraints. E #3 stated she called Security so that the IM injection could be given to Pt. #1. Security was present when she applied the soft wrist restraints. Shortly after, E # 2 notified her that the patient (Pt. #1) was able to "get out of his restraints and tore his scrotal sac and fell sustaining a hematoma at his forehead. The patient broke the restraints (soft) to be able to get out of bed". E #3 stated that she was told to include the scrotal incident in the fall report but she forgot to include it.

5. The Vice President of Nursing Services was made aware of the findings during an interview on 4/12/13 at approximately 2:30 PM and stated that the incident report did not include the patient's self harm.

B. Based on review of documents and interviews, it was determined that for 1 of 1 (Pt. #1) clinical record reviewed of a patient with a documented self injury, the Hospital failed to ensure an occurrence report was completed as required, to help promote patient safety.

Findings include :

1. Hospital policy entitled, "Occurrences," revised date (4/1995) states, "The Hospital needs to establish an efficient and manageable method for receiving and analyzing all occurrence /incidents. All facts must be entered on the occurrence report."

2. The clinical record of Pt. #1 was reviewed on 4/9/13. Pt. #1 was a 54 year old male admitted on 3/17/13 with a Diagnosis of Severe Hyponatremia, Aggressive Behavior, Suicide Attempt, and history of Schizophrenia. Nursing documentation dated 3/20/13 at 1:10 AM indicated, " Patient seen on bed fully awake, aggressive behavior still noted. Patient is with soft limb restraint on both arms with sitter 1:1 at bedside. His scrotal skin is torn apart, patient intentionally torn his scrotal sac apart. "

3. The Hospital's incident reports for March 2013 were reviewed on 4/9/13 at approximately 1:00 PM. The reports included documentation that on 3/20/13 at 1:10 AM Pt #1 was able to get out of the soft restraints, out of bed, and fall. The occurrence report lacked documentation regarding Pt#1's laceration of the scrotum.

4. The Vice- President of Nursing Services (E # 1) was interviewed on 4/9/13 at approximately 1:00 PM. E # 1 stated that the Hospital's occurrence report dated 3/20/13 included Pt #1's fall but not laceration of the scrotum with his long finger nails.

5. On April 10, 2013 at approximately 8:30 AM, the Registered Nurse (E #3) on duty the date of Pt.#1's incident was interviewed. E#3 stated that at approximately 2:00 AM, Pt #1's sitter notified her that Pt. #1 was able to get out of his restraints and tore his scrotal sac.

E#3 stated that she was told to include the scrotal laceration and Pt #1's fall on the same report but she forgot to include it.

C. Based on review of documents and interview, it was determined that in 2 of 3 (Pt #1 and 7) clinical records reviewed of patients requiring safety monitoring checks every 15 minutes, the Hospital failed to ensure the patients were monitored for safety, as required.

Findings include:

1. Hospital policy entitled, "One-to-One Supervision" required, "5. Staff supervising the patient's safety will document behavioral observations every 15 minutes on the Observation flowsheet..."

2. The clinical record of Pt #1 was reviewed on 4/9/13 at approximately 1:30 PM. Pt #1 was a 54 year old male admitted on 3/17/13 with diagnoses of Aggressive Behavior, Severe Hyponatremia, Suicide Attempt, and History of Schizophrenia. Pt #1's clinical record did not contain physicians' orders for special observational checks, however Pt #1 was placed on Assault, Elopement, and Suicide Precautions as well as 1:1 monitoring by nursing action. Pt #1's clinical record contained an Observation Record dated 3/21/13 that lacked safety monitoring checks every 15 minutes from 6:45 PM to 7:30 PM.

3. The clinical record of Pt #7 was reviewed on 4/10/13 at approximately 1:30 PM. Pt #7 was a 61 year old female admitted on 4/1/13 with a diagnosis of Acute Respiratory Failure. Pt #7's clinical record did not contain physicians' orders for special observational checks, however Pt #7 was placed on Fall Reduction Precautions by nursing action, requiring safety checks every 15 minutes, following the removal of restraints. Pt #7's Observation Record dated 4/9/13 lacked documentation of safety monitoring checks every 15 minutes from 2:00 PM to 3:00 PM and 11:15 PM to 12:00 PM.

4. During interviews on 4/9/13 at approximately 1:30 PM and 4/10/13 at approximately 1:30 PM, the Vice President of Nursing Services verified the findings.

Based on review of documents and interview, it was determined that in 2 of 3 (Pt #1 and 7) clinical records reviewed of patients that were restrained, the Hospital failed to ensure least restrictive measures were attempted prior to the application of restraint devices.

Findings include:

1. Hospital policy entitled "Patient Care Services Utilization of Human Restraint," (revised 2/10) required, Initiation Of Restraint or Seclusion: 1. Each use of physical restraint...requires a written physician's order which shall include the type of restraint employed, specific time frames and clinical justification for usage."

2. The clinical record of Pt #1 was reviewed on 4/9/13 at approximately 1:30 PM. Pt #1 was a 54 year old male admitted on 3/17/13 with diagnoses of Aggressive Behavior, Severe Hyponatremia, Suicide Attempt, and History of Schizophrenia. Pt #1's clinical record contained physicians' Restraint and Seclusion Orders dated 3/20/13 at 9:00 AM, 1:00 PM, and 5:00 PM; 3/24/13 at 11:00 AM, 3:00 PM, 7:00 PM, and 11:00 PM; 3/25/13 at 3:00 AM, 7:00 AM, 11:30 AM, and 3:30 PM. The orders, which required this documentation on the order, lacked Alternatives Attempted Prior to Restraint/Seclusion.

3. The clinical record of Pt #7 was reviewed on 4/10/13 at approximately 1:30 PM. Pt #7 was a 61 year old female admitted on 4/1/13 with a diagnosis of Acute Respiratory Failure. The clinical record of Pt #7 contained a physician's order for restraint device usage dated 3/31/13. The order, which required this documentation on the order, lacked documentation of Alternatives Attempted Prior to Restraint/Seclusion.

4. During interviews on 4/9/13 at approximately 1:30 PM and 4/10/13 at approximately 1:30 PM, the findings were verified by the Vice President of Nursing Services.

Based on review of documents and interview, it was determined that in 2 of 3 (Pt #1 and 7) clinical records reviewed of patients that were restrained, the Hospital failed to ensure restraint orders included type of restraints to be used.

Findings include:

1. Hospital policy entitled "Patient Care Services Utilization of Human Restraint," (revised 2/10) required, Initiation Of Restraint or Seclusion: 1. Each use of physical restraint...requires a written physician's order which shall include...the type of restraint employed..."

2. The clinical record of Pt #1 was reviewed on 4/9/13 at approximately 1:30 PM. Pt #1 was a 54 year old male admitted on 3/17/13 with diagnoses of Aggressive Behavior, Severe Hyponatremia, Suicide Attempt, and History of Schizophrenia. Pt #1's clinical record contained a physician's order for restraint usage dated 3/25/13 at 3:30 PM that did not not include the type of restraint device to be applied.

3. The clinical record of Pt #7 was reviewed on 4/10/13 at approximately 1:30 PM. Pt #7 was a 61 year old female admitted on 4/1/13 with a diagnosis of Acute Respiratory Failure. The clinical record contained a physician's order dated 3/31/13 that required the use of restraint devices. The order lacked documentation of the type of restraint device to be used.

4. During interviews on 4/9/13 at approximately 1:30 PM and 4/10/13 at approximately 1:30 PM, the findings were verified by the Vice President of Nursing Services.

Based on review of documents and interview, it was determined that in 1 of 3 (Pt #1) clinical records reviewed of patients that were restrained, the Hospital failed to ensure a written modification to the patient care plan included restraint usage.

Findings include:

1. Hospital policy entitled "Patient Care Services Utilization of Human Restraint," (revised 2/10) was reviewed on 4/9/13 at approximately 1:00 PM. The policy failed to include the requirement that patient care plans include restraint usage.

2. Hospital policy entitled, "Patient Care Plan," (reviewed 10/11) required, "Procedure: The Nursing Care Plan will be updated on a regular basis by the Professional Nurse as the needs and/or condition of the patient dictates."

3. The clinical record of Pt #1 was reviewed on 4/9/13 at approximately 1:30 PM. Pt #1 was a 54 year old male admitted on 3/17/13 with diagnoses of Aggressive Behavior, Severe Hyponatremia, Suicide Attempt, and History of Schizophrenia. Pt #1's clinical record contained documentation that Pt #1 was in restraints on 3/17, 3/18, 3/20, 3/21, 3/22, 3/23, 3/24, and 3/25/13. Pt #1's Plan of Care failed to include the usage of restraint devices.

4. During an interview on 4/9/13 at approximately 1:30 PM the finding was verified by the Vice President of Nursing Services.

Based on review of documents and interview, it was determined that in 1 of 3 (Pt #1) clinical records reviewed of patients that were restrained, the Hospital failed to ensure a signed physician's order was obtained for the application of restraint devices.

Findings include:

1. Hospital policy entitled "Patient Care Services Utilization of Human Restraint," (revised 2/10) required, Initiation of Restraint or Seclusion: 1. Each use of physical restraint...requires a written physician's order which shall include the type of restraint employed, specific time frames and clinical justification for usage."

2. The clinical record of Pt #1 was reviewed on 4/9/13 at approximately 1:30 PM. Pt #1 was a 54 year old male admitted on 3/17/13 with diagnoses of Aggressive Behavior, Severe Hyponatremia, Suicide Attempt, and History of Schizophrenia. Pt #1's clinical record contained Restraint and Seclusion orders that required locked wrist and ankle restraints, dated 3/18/13 at 1:00 PM, 3/23/13 at 6:45 AM, 3/25/13 at 11:30 AM, and 3/25/13 at 3:30 PM, without signed physician's orders.

3. During an interview on 4/9/13 at approximately 1:30 PM, the finding was verified by the Vice President of Nursing Services.

Based on review of documents and interview, it was determined that in 1 of 3 (Pt #1) clinical records reviewed of patients that were restrained, the Hospital failed to ensure restraint orders included the specific duration of usage.

Findings include:

1. Hospital policy entitled "Patient Care Services Utilization of Human Restraint," (revised 2/10) required, Initiation Of Restraint or Seclusion: 1. Each use of physical restraint...requires a written physician's order which shall include...specific time frames...a. Four (4) hours for patients 18 years and older."

2. The clinical record of Pt #1 was reviewed on 4/9/13 at approximately 1:30 PM. Pt #1 was a 54 year old male admitted on 3/17/13 with diagnoses of Aggressive Behavior, Severe Hyponatremia, Suicide Attempt, and History of Schizophrenia. Pt #1's clinical record contained Restraint and Seclusion orders dated 3/20/13 at 1:00 PM, and 5:00 PM, on 3/23/13 at 5:00 PM, on 3/24/13 at 11:00 PM, and on 3/25/13 at 3:00 AM and 7:00 AM that did not not include the required length of time the restraints were to be applied.

3. During an interview on 4/9/13 at approximately 1:30 PM the finding was verified by the Vice President of Nursing Services.

Based on Hospital documents and staff interview, it was determined that in 2 of 3 (Pt #1 and 8) clinical records reviewed of patients that were restrained, the Hospital failed to ensure patient observation as required.

Findings include:

1. Hospital policy entitled "Patient Care Services Utilization of Human Restraint," (revised 2/10) required, "Care of the Patient In Physical Restraint: 4. The restrained patient's pulse and respiration will be assessed every two hours. 5. The patient placed in restraint shall be offered fluids and toileting opportunities every two hours while awake. 11. The care of the patient in physical restraints shall be documented on the 'Observation/Restraint Flow Sheet' ".

2. The clinical record of Pt #1 was reviewed on 4/9/13 at approximately 1:30 PM. Pt #1 was a 54 year old male admitted on 3/17/13 with diagnoses of Aggressive Behavior, Severe Hyponatremia, Suicide Attempt, and History of Schizophrenia. Pt #1's clinical record contained a Restraint Seclusion order dated 3/23/13 at 5:00 PM that required the use of locked restraints. The clinical record lacked an Observation/Restraint Flow Sheet that documented patient care every 2 hours as required.

3. The clinical record of Pt #8 was reviewed on 4/10/13 at approximately 1:30 PM. Pt #8 was a 69 year old male admitted on 4/9/13 with diagnoses of Hospital Acquired Pneumonia and Congestive Heart Failure Exacerbation. The clinical record of Pt #8 contained documentation that Pt #8 was restrained on 4/9/13. The clinical record contained an Observation/Restraint Flow Sheet dated 4/9/13 that lacked safety checks every 2 hours from 4:00 PM to 8:00 PM.

4. During interviews on 4/9/13 at approximately 1:30 PM and 4/10/13 at approximately 1:30 PM, the findings were verified by the Vice President of Nursing Services.

Based on review of documents and interview, it was determined that in 2 of 3 (Pt #1 and 7) clinical records reviewed of patients that were restrained, the Hospital failed to ensure rational for restraint usage was documented.

Findings include:

1. Hospital policy entitled "Patient Care Services Utilization of Human Restraint," (revised 2/10) required, Initiation Of Restraint or Seclusion: 2. A progress note will accompany an order, detailing events that led up to the need for use of physical restraint."

2. The clinical record of Pt #1 was reviewed on 4/9/13 at approximately 1:30 PM. Pt #1 was a 54 year old male admitted on 3/17/13 with diagnoses of Aggressive Behavior, Severe Hyponatremia, Suicide Attempt, Orders dated 3/20/13 at 9:00 AM, 3/20/13 at 1:00 PM, 3/20/13 at 5:00 PM, 3/24/13 at 3:00 PM, 3/24/13 7:00 PM, 3/24/13 at 11:00 PM, 3/25/13 at 3:00 AM, and 3/25/13 at 7:00 AM that lacked documentation of the Rational For Use of the Restraint Devices.

3. The clinical record of Pt #7 was reviewed on 4/10/13 at approximately 1:30 PM. Pt #7 was a 61 year old female admitted on 4/1/13 with a diagnosis of Acute Respiratory Failure. The clinical record contained Restraint and Seclusion Orders dated 4/3 and 4/8/13 that required the use of restraint devices that lacked documentation of the Rational For Use of Restraint.

4. During interviews on 4/9/13 at approximately 1:30 PM and 4/10/13 at approximately 1:45 PM the findings were verified by the Vice President of Nursing Services.

A. Based on review of documents and interview, it was determined that for 1 of 3 (Pt #1) patients with special precautions, the Hospital failed to ensure Nursing staff obtain physicians' orders for all precautions initiated, as required by policy.

Findings include:

1. Hospital policy entitled "One-to-One Supervision," (reviewed 9/10) required, "Procedure: 1...If program staff evaluates the necessity of placing a patient on one-to-one supervision, the attending physician will be notified and an order obtained within one hour."

2. Hospital policy entitled "Close Observation," (reviewed 9/10) required, "Procedure: 2...If program staff place a patient on Close Observation, the attending physician will be consulted and a physician's order obtained within one hour."

3. Hospital policy entitled "Identification and Management of Patients at Risk of Suicide," (reviewed 10/12) required, "Suicide Precautions will be instituted:...1. Patients will be placed on Suicide Precautions by a physician's written or verbal order. The order will be dated and timed. 2. The order will specify the level of observation: Close Observation every 15 minutes, Continuous Supervision, or 1:1 Observation...6. Patients placed on these precautionary levels will be re-evaluated by completion of the Suicide Risk Assessment on a daily basis."

4. The clinical record of Pt #1 was reviewed on 4/9/13 at approximately 1:30 PM. Pt #1 was a 54 year old male admitted on 3/17/13 with diagnoses of Aggressive Behavior, Severe Hyponatremia, Suicide Attempt, and History of Schizophrenia. Pt #1's clinical record contained Observation Records dated 3/17, 3/18, 3/19, 3/20, 3/21, 3/22, 3/23, 3/24, and 3/25/13 that indicated Pt #1 was monitored on Assault, Elopement, Suicide, and 1:1 Supervision without physicians' orders for the precautions.

5. The finding was verified the Vice President of Nursing Services during an interview on 4/9/13 at approximately 1:30 PM.

B. Based on review of documents and interview, it was determined that for 1 of 2 (Pt #1) patients on suicide precautions, the Hospital failed to ensure daily Suicide Risk reassessments were completed as required.

Findings include:

1. Hospital policy entitled "Identification and Management of Patients at Risk of Suicide," (reviewed 10/12) required, "Suicide Precautions will be instituted:...1. Patients will be placed on Suicide Precautions by a physician's written or verbal order. The order will be dated and timed. 2. The order will specify the level of observation: Close Observation every 15 minutes, Continuous Supervision, or 1:1 Observation...6. Patients placed on these precautionary levels will be re-evaluated by completion of the Suicide Risk Assessment on a daily basis."

2. The clinical record of Pt #1 was reviewed on 4/9/13 at approximately 1:30 PM. Pt #1 was a 54 year old male admitted on 3/17/13 with diagnoses of Aggressive Behavior, Severe Hyponatremia, Suicide Attempt, and History of Schizophrenia. Pt #1's clinical record contained Observation Records dated 3/17, 3/18, 3/19, 3/20, 3/21, 3/22, 3/23, 3/24, and 3/25/13 that indicated Pt #1 was being monitored on Suicide precautions however the clinical record lacked daily Suicide Risk Reassessments, as required.

3. The finding was verified by the Vice President of Nursing Services during an interview on 4/9/13 at approximately 1:30 PM.

C. Based on review of documents and interview, it was determined that in 1 of 2 (Pt #1) clinical records reviewed of a patient with a surgical wound, the Hospital failed to ensure daily wound assessments were completed as required.

Findings include:

1. Hospital policy entitled, "Wound Care," (reviewed 2/10/10) required, "Guidelines for Wound Care: 1. Skin integrity will be documented on a daily basis using the 'Nurse Shift Progress Note' available in the EMR (Enterprise Medical Record)."

2. The clinical record of Pt #1 was reviewed on 4/9/13 at approximately 1:30 PM. Pt #1 was a 54 year old male admitted on 3/17/13 with diagnoses of Aggressive Behavior, Severe Hyponatremia, Suicide Attempt, and History of Schizophrenia. Nursing documentation dated 3/20/13 at 1:10 AM indicated, "Patient seen on bed fully awake, aggressive behavior still noted. Patient is with soft limb restraint on both arms with sitter 1:1 at bedside. His scrotal skin is torn apart, patient intentionally torn his scrotal sac apart."

At 2:40 AM on 3/21/13, a consult was obtained by Urology for scrotal repair. A consent was signed and on 3/20/13 at 1:55 PM, Pt #1 underwent a Closure and repair of Scrotum. Pt #1 returned to his room at 2:00 PM, "awake, alert, not in distress. Post op dressing on the scrotal area intact and dry."

Pt #1's clinical record lacked wound assessment on 3/23, 3/24, and 3/25/13 to 4/9/13.

3. The findings were verified by the Vice President of Nursing Services during an interview on 4/11/13 at approximately 11:00 AM.

Based on review of documents and interview, it was determined that in 1 of 10 (Pt #1) clinical records reviewed for PRN (as needed) medication administration, the Hospital failed to ensure PRN medication reassessments, as required.

Findings include:

1. Hospital policy entitled, "Medication Administration Record," (reviewed 10/11) required, "Policy: 6. The Registered Nurse/Licensed Practical Nurse shall re-assess those patients receiving PRN medications and document the patient's response on the M.A.R."

2. The clinical record of Pt. #1 was reviewed on 4/9/13. Pt. #1 was a 54 year old male admitted on 3/17/13 with a Diagnosis of Severe Hyponatremia, Aggressive Behavior, Suicide Attempt, and history of Schizophrenia. Pt #1's clinical record contained physicians' orders from 3/17/13 through 3/26/13 for Haldol and Ativan as needed for psychosis and agitation.

Pt #1 received multiple doses of Ativan 2 mg IM PRN. Examples are: 3/17/13 at 11:09 AM and 5:00 PM; 3/18/13 at 1:04 AM. Pt #1 also received multiple doses of Haldol IM PRN. Examples are: 3/17/13 at 9:25 PM; 3/19/13 at 4:05 AM.

The clinical record lacked documentation of PRN medication reassessments as required from 3/17/13 to 3/25/13.

3. The findings were verified by the Vice President of Nursing Services during an interview on 4/11/13 at approximately 11:00 AM.