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Based on observation, interview, record review and policy review, the facility failed to:
- Adequately supervise and evaluate patients in their behavioral health unit (BHU) by failing to conduct patient safety rounds in a random fashion.
- Ensure staff documented, in real time, when the patients were observed during the patient safety rounding.
- Ensure each patient was actually accounted for and in the appropriate room, during patient safety rounding.
- Ensure each patients' environment was free of contraband.
- Ensure facility safety checklists were completed every shift to promote a safe physical environment and identify potential safety hazards.
- Provide adequate supervision to keep patients safe from access to long cords, tubes, and electrical equipment.
- Provide adequate supervision to keep patients safe from hazardous alcohol-based hand sanitizer.
- Provide adequate supervision to keep patients safe from glass doors on two of two fire extinguisher cabinets.
- Adequately assess patients' medical care needs, patients' health status, and patients' response to interventions.
Please refer to A0395 for citations.

These deficient practices and systemic failures had the potential to affect all patients on the BHU. The facility census was 15 with 14 patients in the BHU.

These systemic failures contributed to the facility's failure to meet the minimum requirements for the Condition of Participation: Nursing Services.

Based on observation, interview, record review and policy review, the facility failed to:
-Adequately supervise and evaluate patients in their behavioral health unit (BHU) by failing to conduct patient safety rounds in a random fashion and ensure staff documented, in real time, when the patients were observed during the patient safety rounds for 14 patients (#2, #3. #4, #5, #6, #11, #12, #13, #14, #15, #21, #22, #23 and #24) of 14 patients safety rounding sheets reviewed.
- Ensure each patient was actually accounted for and in the appropriate room, during patient safety rounds for one patient (#14) of 14 patients.
- Ensure each patients' environment was free of contraband for three patients (#4, #11 and #22) of 10 patients' environments observed.
- Ensure facility safety checklists were completed every shift to promote a safe physical environment and identify potential safety hazards for two patients (#2 and #5) of 10 patients' physical environments observed.
- Provide adequate supervision to keep patients safe from access to long cords, tubes, and electrical equipment for eight (#203, #206, #207, #208,
#209, #211, #303, and #306) of 10 patient rooms observed .
- Provide adequate supervision to keep patients safe from hazardous alcohol-based hand sanitizer in one of two bathrooms observed, located in an unmonitored alcove.
- Provide adequate supervision to keep patients safe from glass doors on two of two fire extinguisher cabinets.
-Ensure adequate monitoring and supervision of the use of a continuous positive pressure (CPAP) machine (used for patients who suffer from sleep apnea, which is a potential serious sleep disorder in which breathing repeatedly stops and starts) for one (#3) of one patient with CPAP observed.
- Assess the patient's medical care needs, patient's health status, and patient's response to interventions for one patient (#15) of nine patients reviewed.

These failures had the potential to affect all patients admitted to the BHU with the potential to lead to unrecognized patient injury and self harm. These failures also had the potential to affect all patients' medical care needs.
The facility census was 15 with 14 patients in the BHU.

Findings included:

The facility provided a list of current patients that were identified as suicidal and/or homicidal (thoughts to do self harm or harm to others) that included Patients #8, #12, #14, and #21. The facility also identified one patient (#24) who wandered into other patients' rooms and throughout the unit (this allowed any hazardous item, in any room, accessible to this patient).

1. Record review of the facility's policy titled, "Special Precautions Patient Observation Record," revised 09/2014 showed direction for the BHU staff to monitor and observe patients on a regular timeframe to ensure they were medically stable, safe and received appropriate treatment. Patients were to be monitored and observed on 15 minute timeframe. Each patient would have documentation entered onto the Special Precautions Patient Observation Record (staff referred to these as patient safety rounding forms).

Record review of the facility's policy titled, "Patient Observation Categories, Special Precautions," revised 11/2014 showed that routine precautions directed the staff that they were to be aware of patient's whereabouts at all times.

Record review of the facility's care plan problem list for patients with depression, suicide risks direct staff to:
- Ensure that nursing rounds are frequent and irregular, especially at predictably busy times like change of shift and early morning.
- Make surveillance unpredictable;
- Maintain awareness of patient location at all times.

2. Record review of 14 patient safety rounding forms (one for each patient), dated 01/20/15 at 2:40 PM, showed all entries were documented exactly every 15 minutes.

During an interview on 01/20/15 at 3:27 PM, Staff B, Registered Nurse (RN) Supervisor, stated that he expected staff to document in real time when staff observed patients during patient safety rounding, but his staff did not wear watches so they documented in 15 minute increments instead (so they would not have to look at a watch).

During an interview on 01/20/15 at 2:35 PM, Staff D, Patient Care Technician (PCT) stated that she completed her patient safety rounding by chronological, numerical room number order each time she did rounds.

3. Record review of the rounding forms and concurrent interview on 01/21/15 from 11:17 PM through 12:15 AM showed the following:
- Patient #14 was admitted to room #308 with suicidal ideations, depression, dementia and behavioral disturbances. The patient's care plan, dated 01/20/15, directed staff to monitor her every 15-minutes, staggering the monitoring so as not to be predictable, that she was to remain in view of staff at all times, and maintain awareness of her whereabouts at all times.
- Patient #14's patient safety rounding form dated 01/21/15, showed Patient #14 was in room #308 from 8:15 PM through 11:15 PM, as documented by Staffs V, T and W (even though it was later determined the patient was not actually in this room).
- Review of Patient #3's and #6's patient safety rounding forms, at 11:17 PM (surveyors' arrival), showed the "actual times" column of the patient safety rounds forms had been documented in advance, in 15 minute increments, up through 12:45 AM. The patients' whereabouts and behaviors columns were still blank.
- Review of all patients' safety rounding forms showed the last documentation of where the patients were, their behaviors, and the staff members' initials doing the rounds, was at 10:45 PM, or showing staff had failed to round for about 30 minutes (10:45-11:17 PM).
- Staff T, RN stated that she had pre-documented the times in the patient safety rounding forms in advance to assist the PCTs in getting them done on time.

4. Observations on 01/21/15 from 11:17 PM through 12:15 AM, and concurrent interviews showed the following:
- The patient door to room #308 was locked (Patient #14's assigned room.)
- Staff W unlocked the door to room #308 and the light was on, but Patient #14 was not in the room.
- The two RNs (Staffs T and U) and two PCTs (Staffs V and W), searched for Patient #14 for 15 minutes questioning each other about where the patient was, before the patient was found in room #309 (Patient #15's room).

5. During an interview on 01/22/15 at 11:38 AM, Staff S, Psychiatrist (a doctor that treats mental disorders), stated the following:
- The safety rounds were conducted to ensure patients were where they were supposed to be.
- Patients wander, many things happen.
- It was important to verify where the patients were on the unit, and that they were safe.

6. Record review of the facility's policy titled, "Contraband, Sharps, and Prohibited Items," revised 09/2014 showed:
- The psychiatric unit will ensure the safety and welfare of patients, visitors, and staff by managing the availability of contraband, sharps, and prohibited items.
- Contraband is any weapon or item that could be used as a weapon that poses a danger to patients or staff members.
- Contraband included but not limited to glass, hard plastic items, prescription or non prescription medications, and alcohol.

Record review of the facility's policy titled, "Unit Safety Guidelines," revised 09/2014, showed the following:
- Every patient has the right to receive treatment and care in a safe setting.
- Ongoing monitoring of the unit ensures the safety of patients and staff.
- At least one time per shift, during nursing rounds rooms were inspected for unsafe articles and cleanliness.
- Appliances with cords are kept in locked cabinets until staff need for patient use.

Record review of the facility's policy titled, "Facility Safety Checklist," revised 09/2014, showed the following:
- The facility safety checklist was to help promote a safe physical environment for patients, personnel and visitors.
- The checklists were to be completed every shift by a designated staff person.
- Completed checklists were to be kept as part of the performance improvement manual.
- A general surveillance of each room was to be made every shift.
- Windows were to be inspected including window blinds.
- Walls are to be inspected for damage.
- Remove any glass items.
- Cords were to be secured to 6" or less.

Record review of the facility's policy titled, "Admission Process to the Unit," revised 09/2014 showed the RN was to conduct a complete search for contraband and all items found were to be inventoried, locked and secured. PCT's were also to check the patient's belongings for contraband items and not allow the patient to keep such items.

7. Observation on the BHU on 01/20/15 at 2:20 PM showed the following safety concerns:
- Electric hospital beds with 3-4' of cord accessible to patients in rooms
#203 (Patient #3), #206 (Patient #22), #207 (Patient #11), #208 (Patient #25), #209 (Patient #13), #211 (Patient #5), #303 (Patient #4), and #306 (Patient #2.)
- Patient #3's CPAP machine on a bedside chair with approximately 6-8' of plastic tubing, a Velcro elastic head strap and two removable electrical cords approximately 5-6' long in room #203. (The elastic head strap could also be used to self harm as a hanging device and ligature in addition to the longs cords and tubing).
- Two topical (applied to skin) creams/medications at patient bedside in rooms #206 (Patient #22) and #207 (Patient #11).
- Plastic bags approximately 8" x 12" containing green plastic patient incontinent briefs inside rooms #206 (Patient #22) and #303 (Patient #4). (Plastic bags large enough to cover the nose and mouth could be used as a suffocation device and are considered contraband).
- Ink pen inside patient eyeglass case in room #207. (Ink pens could be used as a weapon for self harm or harm to others and are considered contraband).
- Hole in exterior wall approximately 1?" x 3" located to the right of the patient bed, approximately 3-4" from the electrical receptacle (plug in) for the hospital bed in room #211 (Patient #5.) The wallpaper had been cut and was able to be pulled back exposing interior sheetrock and pink insulation. (Holes in the wall with close location to electrical outlets could be used by patients for self harm).
- Removable aluminum rod approximately four feet long, used to weight window blinds down in room #306 (Patient #2). (Long aluminum or metal rods could be used as a weapon to do self harm or harm to others).
- Two empty wall mounted fire extinguisher cabinets with glass doors, one in each patient hallway.
- One unlocked bathroom at the end of a patient hallway, in an unmonitored alcove, with wall mounted hand sanitizer that contained alcohol.

8. Observation on 01/21/15 at 3:25 PM, showed three incontinence briefs, in a plastic bag container, on a shelf in room #206. Even though Staff F, Risk Manager had been made aware of this-type of hazard on 01/20/15 at 2:20 PM, and daily rounds to identify hazards were to have been done at the beginning of the night shift (7:00 PM) on 01/20/15, and additional rounds were to have been done at the beginning of the day shift (7:00 AM) on 01/21/15, plastic bags were still accessible to all patients.

9. During an interview on 01/21/15 at 10:41 AM, Staff B stated that Patient #24 had dementia and wandered about (these behaviors put the patient at an increased risk for obtaining and/or utilizing hazardous items from any room).

During an interview on 01/20/15 at 3:30 PM, Staff F, Risk Management verified the safety concerns found and stated the electric bed cords should be tied with plastic ties. She stated the ink pen and aluminum rod would be considered contraband. She stated she was unaware of the hole in the exterior wall and that all patients used the unlocked bathroom located in an unmonitored alcove.

During an interview on 01/21/15 at 10:41 AM, Staff B, stated that staff were to do a search of each room for contraband at the beginning of each shift. Staff B stated that visitors brought restricted items into the BHU and that visitors were not searched for contraband. Sharp items, pens/pencils, plastic bags, and plastic disposable briefs were considered to be unsafe items.

During an interview on 01/21/15 at 3:23 PM, Staff D, PCT, stated that there was no list/checklist to use while doing environmental safety rounds, so the rounds were not documented. Staff D also stated this task was not assigned, but should be completed at the beginning of each shift. Staff D confirmed plastic bags and pens were considered contraband. Staff failed to follow their checklist policy.

10. Record review of the facility's policy titled, "Patient Observation Categories, Special Precautions," revised 11/2014 showed each patient will be assigned an observation category at the time of admission. Special Precautions III (visual contact) required constant observation by staff.

11. Record review of Patient #3's Psychiatric (relating to mental illness or its treatment) Evaluation dated 01/09/15 showed the following medical history:
- Major suicide attempt that resulted in hospitalization in a medical intensive care unit;
- Found unresponsive in a hotel room;
- Depression;
- Dementia (decline in mental ability severe enough to interfere with daily life);
- Pseudodementia (a severe form of depression that results from a progressive brain disorder in which cognitive changes mimic those of dementia).
- Plan and recommendation was to admit patient to BHU for medication adjustments and treatment.

During an interview on 01/21/15 at 4:20 PM, Staff C, Licensed Practical Nurse (LPN) stated she completed the intake assessment form for Patient #3 upon her admission. She stated that the patient brought her own CPAP equipment. She stated the patient was a level III (a special precaution given to patients that require visual contact, constant observation by staff) due to her seriousness of suicide attempt. She stated she didn't think about the CPAP tubing or cords being a safety issue with the patient. Staff C stated that it was okay to leave things like that in patient rooms during the daytime because they were not in their rooms during the day.

During an interview on 01/22/15 at 10:50 AM, Staff Y, Respiratory Therapist (RT), stated that the respiratory therapists put the CPAP on the patient but did not stay with her. She stated that it was the responsibility of the nursing staff to maintain observation of the patient during the treatment. Staff Y stated that all patients were expected to be on line of site precautions when the CPAP was on. Staff Y presented documentation that the RT had the patient use the CPAP on 01/11/15, 01/12/15 and 01/13/15.

12. Review of the facility's policy titled, "Charting Standards for Med/Surg (Medical/Surgical)," dated 01/2015 showed reassessment is an ongoing process. The nurse responsible for the individual patient's care should be alert to any changes in condition that would warrant a reassessment and possible change in care or treatment needs.

13. Record review of Patient #15's Psychiatric Evaluation dated 01/17/15 showed the following medical history:
- Degenerative joint disease and osteoarthritis (inflammation, breakdown and eventual loss of the cartilage [flexible connective tissue found in joints between bones] of the joints) with chronic back pain.
- Hypertension (high blood pressure) with right sided stroke; and
- Plan and recommendation for the patient to see a hospitalist (physician who specializes in the practice of hospital medicine) for adjustment of his medical medications according to general medical condition.

Record review of Patient #15's Vital Signs (Temperature, heart rate, respirations and blood pressure [B/P]) Flow sheet showed the following:
- Vital signs were ordered to be checked every twelve hours.
- On 01/15/15 at 7:24 PM his B/P was elevated at 194/86;
- On 01/19/15 at 9:47 PM his B/P was elevated at 160/90.
- There were no vital signs documented in the medical record on 01/20/15 and 01/21/15 with a notation that the patient had refused to have vital signs taken.
Further record review of the Patient Care Notes and Patient Care Worklist showed no evidence that the elevated B/P was re-evaluated or the physician notified.

During an interview on 01/21/15 at approximately 12:45 PM, Staff T, RN, stated that when a patient's blood pressure was found to be elevated it was rechecked to verify the accuracy of the reading and the medical physician was notified if it was still elevated. Staff T could not show evidence that the B/P had been re-evaluated or the physician had been notified of the elevated B/P for Patient #15.

During observation and concurrent interview on 01/21/14 at 3:20 PM, in the BHU day room showed Patient #15 sitting on a small sofa. He was frequently moving about adjusting his sitting position. He stated that he was experiencing severe back pain and rated his pain as a 10 (based on a scale of 1-10 with 10 being the highest pain). He stated that the staff had not given him anything for pain that day; that he was only getting Ibuprofen 200 mg in the hospital; that he took Ibuprofen 400 mg at home and the Ibuprofen the staff were giving him did not help his pain.

Record review of Patient #15's Progress Notes dated 01/15/15, showed he was assessed by the hospitalist for a chronic back pain flare up. An order was written on 01/15/15 at 2:35 PM for Ibuprofen (medication that works by reducing hormones that cause inflammation and pain in the body) 200 mg to be given every four hours as needed for pain.

Record review of Patient #15's Patient Care Notes and Medication Administration Records showed the following:
- He was given Ibuprofen 200 mg on 01/15/15 at 3:24 PM. There was no record the patient was re-assessed to determine if the Ibuprofen were effective at relieving his pain.
- He was assessed as experiencing severe lower back pain rated as 10 on 01/15/15 at 8:12 PM. There was no record of Ibuprofen being administered.
- He was assessed as experiencing severe lower back pain rated as 10 on 01/17/15 at 8:20 PM. There was no record of Ibuprofen being administered.
- He was given Ibuprofen 200 mg on 01/19/15 at 2:01 PM for pain. There was no record the patient was re-assessed to determine if the Ibuprofen was effective.
- He was given Ibuprofen 200 mg on 01/20/15 at 9:13 AM for pain. There was no record the patient was re-assessed to determine if the Ibuprofen was effective.









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Based on observation, interview, record review, and policy review, the facility failed to develop a nursing care plan that addressed all patient care needs and included measurable goals and interventions for five patients (#15, #8, #13, #12 and #3) of nine patients' nursing care plans reviewed. The failure to develop comprehensive care plans for patients' individual needs had the potential to result in lack of care for problems not identified for all patients in the behavioral health unit (BHU.)
The facility census was 15 with 14 patients in the BHU.

Findings included:

1. Record review of the facility's policy titled, "Charting Standards for Med/Surg (Medical/Surgical)," dated 01/2015 showed the following direction:
- A registered nurse (RN) develops an individualized plan of nursing care for each patient within 24 hours of admission based on the initial nursing assessment.
- Data is obtained by interview, physical examination, observation and the review of the client's medical record and reports.
- The care plan will include goals that are based on the nursing assessment and will be realistic, measurable and consistent with the therapy provided.
- Response to interventions are indicated and charted on the care plans.
- All care plans are reviewed at least every 24 hours by a registered nurse or practical nurse and updated as needed.
- Reassessment is an ongoing process. The nurse responsible for the individual patient's care should be alert to any changes in condition that would warrant a reassessment and possible change in care or treatment needs.

2. Record review of Patient #15's Progress Notes dated 01/15/15, showed he was assessed by the medical physician as having a chronic back pain flare up. An order was written on 01/15/15 at 2:35 PM for Ibuprofen (medication that works by reducing hormones that cause inflammation and pain in the body) 200 mg to be given every four hours as needed for pain.

Record review of Patient #15's Psychiatric (relating to mental illness or its treatment) Evaluation dated 01/17/15 showed a history of degenerative joint disease and osteoarthritis (type of arthritis caused by inflammation, breakdown and eventual loss of the cartilage of the joints) with chronic back pain and a history of Hypertension (high blood pressure) with right sided stroke.

Observation in the BHU day room, and concurrent interview on 01/21/14 at 3:20 PM, showed Patient #15 sitting on a small sofa. He was frequently moving about shifting his sitting position and grimacing (a sharp contortion of the face expressive of pain). He stated that he was experiencing severe back pain and rated his pain as a 10 (based on a scale of 1-10 with 10 being the highest pain).

Record review of Patient #15's Patient Care Notes and Medication Administration Records showed the following:
- Staff administered Ibuprofen 200 mg on 01/15/15 at 3:24 PM.
- The patient had lower back pain on 01/15/15 at 8:12 PM rated as 10. There was no record of Ibuprofen being administered.
- Staff assessed the patient with severe lower back pain rated 10 on 01/17/15 at 8:20 PM. There was no record of Ibuprofen being administered.
- The patient was given Ibuprofen 200 mg on 01/19/15 at 2:01 PM for pain; and
- The patient was given Ibuprofen 200 mg on 01/20/15 at 9:13 AM for pain.

Record review of Patient #15's Vital Signs (Temperature, heart rate, respirations and blood pressure [B/P]) Flow sheet showed the following:
- Vital signs were ordered to be checked every twelve hours.
- On 01/15/15 at 7:24 PM his B/P was elevated at 194/86 (normal range: top number [systolic] below 120 and bottom number [diastolic] below 80)
- On 01/19/15 at 9:47 PM his B/P was elevated at 160/90.

Record review of Patient #15's Care Plan on 01/22/15, dated 01/14/15, and updated on 01/17/15, showed no problems had been identified or interventions initiated for back pain or hypertension.

3. Record review of Patient #8's Psychiatric Evaluation dated 01/17/15, showed the following:
- The patient was weak and had a history of falls.
- The patient was not able to bear weight on his feet, and used a wheelchair for ambulation.
- The nursing staff were to assist the patient with safety needs.
- The patient had no teeth.

Observation on the BHU and concurrent interview with Patient #8 on 01/21/15 at 4:25 PM showed the following:
- He sat in a wheelchair in the day room.
- He had a large bump on his head behind his left ear, two large bandages on his right forearm, and a scratch on his left hand.
- He stated that he had fallen in the bathroom.

Record review of a Patient Care Note dated 01/22/15, at 6:54 AM, showed staff found the patient on the floor at 6:15 AM. The note showed that the patient got tangled in his bedsheets and fell. The patient's left wrist was swollen, which he refused to move, and his left hip was painful.

Record review of the patient's care plan on 01/22/15, dated 01/14/15, showed the following:
- The patient was considered a fall risk with a goal to be free of injury.
- All interventions were dated 01/14/15, or prior to the patient's fall. Staff failed to update the care plan with pertinent interventions and goal to prevent future falls.
- The care plan failed to address Patient #8's difficulty eating because he had no teeth.

4. Review of the facility's policy titled, "Skin Assessment," dated 09/2014, specified for the BHU, showed patients whose Braden Scale score (a score derived from a scale of factors used by nurses that predict the degree of risk patient's had for development of pressure ulcers, which are lesions caused by unrelieved pressure that result in tissue damage tissue) of 18 or lower required a care plan/treatment plan developed for the treatment and/or prevention of pressure ulcers.

5. Observation on 01/21/15 at 3:55 PM on the BHU showed Patient #13 in a wheelchair in the day room. She was very thin, her mouth and lips were dry, she appeared agitated and yelled loudly at staff when redirected.

During an interview on 01/21/15 at 4:05 PM, Staff C, Licensed Practical Nurse (LPN) assigned care of Patient #13, stated that:
- The patient was admitted for increased aggression, refusal to take medication and refusal to eat or drink (poor nutrition/hydration contributed to increased skin risk).
- Prior to admission, the patient received hospice care (focused on end of life comfort measures for chronic non-curative conditions). However, she did not know why Patient #13 received hospice prior to admission.
- The patient had refused all medications since admission on 01/20/15 and had been aggressive with staff.

Record review on 01/21/15 of Patient #13's initial nursing assessment dated 01/20/15, showed the following:
- The patient was admitted on 01/20/15.
- The patient had a recent history of food and fluid refusal, intake was poor and she required assistance to drink and eat.
- A Braden Scale score of 14 (14 is a moderate risk for the development of pressure ulcers).
- No skin assessment was documented.

Record review of Patient #13's personal care aide worksheet dated 01/21/15 showed documentation of a reddened open skin area on the patient's hip and buttocks.

Record review on 01/21/15 of Patient #13's care plan showed no development of a care plan for the following problems:
- Skin care related to actual or potential risks for pressure ulcers;
- Nutrition and fluid balance related to actual or potential problems;
- Hospice and/or end of life care; and
- Evaluation of medication effectiveness/and or compliance.

During an interview on 01/21/15 at 4:30 PM, Staff B, RN Supervisor, stated that he was aware of Patient #13's skin breakdown, poor food and fluid intake, history of hospice care and medication non-compliance and verified no care plans were developed for the patient's problems. He stated that patients in the BHU do not have care plans developed for medical issues because they are not in the facility for long periods.

6. Record review of Patient #12's Patient Care Note dated 01/19/15 showed:
- Patient admitted on 01/17/15 for increased depression and suicidal attempt.
- Patient was dehydrated and intravenous (within the vein, IV) fluids were started on 01/18/15 for dehydration (body doesn't have enough water and other fluids to carry out its normal functions) and decreased urine output.
- Patient had a Foley catheter (tube used to drain urine from the bladder) upon admission.

Record review of Patient #12's Care Plan showed no care plans or interventions were initiated for the problem of potential for infection related to the Foley catheter or the dehydration.

7. Observation on 01/20/15 at 3:10 PM, showed Patient #3's personal continuous positive airway pressure (CPAP) machine (a machine used for patients who suffer from sleep apnea, a potentially serious sleep disorder in which breathing repeatedly stops and starts) was on a chair next to her bed. There was approximately 6-8' of plastic tubing with a Velcro elastic head strap and two removable electric cords approximately 8-10' in length.

During an interview on 01/21/15 at 3:30 PM Patient #3 stated that she used a CPAP machine at night and had brought her own machine with her. She stated that it had been in her room since she was admitted except for a few days when she thought it needed some repair.

Record review of Patient #3's Psychiatric (relating to mental illness or its treatment) Evaluation dated 01/09/15 showed the following medical history:
- Major suicide attempt that resulted in hospitalization in a medical intensive care unit;
- Found unresponsive in a hotel room;
- Depression;
- Dementia (decline in mental ability severe enough to interfere with daily life);
- Pseudodementia (a severe form of depression that results from a progressive brain disorder in which cognitive changes mimic those of dementia).
- Plan and recommendation was to admit patient to BHU for medication adjustments and treatment.

Record review of Patient #3's Care Plan showed no care plans or interventions were initiated for the problem of sleep apnea and the use of a CPAP machine or the need for increased monitoring and observation due to the potential risks associated with the electrical cords and plastic tubing.

During an interview on 01/22/15 at 2:00 PM Staff B, RN Supervisor stated that:
- Care Plans were developed based on presenting problems, reasons for admission, psychiatric behaviors, fall risk due to medications being administered and unstable co-morbidities (simultaneous presence of chronic diseases or conditions in a patient) determined by the pre-screening examination.
- New unstable problems were added as they came up.
- Care Plans were updated when the problems were resolved or lessened and would be charted as completed.
- When a patient was admitted with a wound or developed a wound after admission it was the expectation that wounds be added to the Care Plan;
- A Foley catheter would be considered an unstable process and should be added to the problems on a Care Plan.




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