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Based on review of hospital policy, interviews with administrative and hospital staff, hospital document review, personnel file reviews and medical record reviews, the hospital's Governing Body failed to ensure an effective Quality Assessment and Performance Improvement program by failing to ensure evaluation and monitoring of corrective actions following repeated incidents of alleged sexual activity on the adolescent unit.

The finding include:

The hospital failed to have an effective Quality Assessment and Performance Improvement program by failing to ensure evaluation and/or monitoring of the development and implementation of initiatives to monitor adolescent patients.

~ cross refer to 482. 21 Quality Assessment and Performance Improvement - Condition A0263.

Based on review of hospital policy, interviews with administrative and hospital staff, hospital document review, personnel file reviews and medical record reviews, the hospital failed to have an effective Quality Assessment and Performance Improvement program by failing to ensure evaluation and/or monitoring of the development and implementation of initiatives to monitor adolescent patients.

The findings include:

The hospital staff failed to ensure corrective actions instituted after an adverse event involving inappropriate sexual contact between patients (#8, #9, #3, and #4) were implemented and monitored for effectiveness.

~ cross refer to 482. 21 Quality Assessment and Performance Improvement - Standard A0286.

Based on review of hospital policy, interviews with administrative and hospital staff, hospital document review, personnel file reviews and medical record reviews, the hospital staff failed to ensure corrective actions instituted after an adverse event involving inappropriate sexual contact between patients (#8, #9, #3, and #4) were implemented and monitored for effectiveness.

The findings include:

Review of hospital policy, "Improving Organizational Performance", revised 09/2011, revealed, "Philosophy (Name of Hospital) is dedicated to providing a safe and secure environment and to providing quality care and services for all patients in a safe, clean, and therapeutic environment through minimization and elimination of risks throughout the facility. Safe patient care and patient services are our primary focus. ...The facility fulfills its responsibilities to patients...through continuous and systematic monitor, aggregation, and analysis of system and process outcomes. ...Improving organizational performance comes from data collection and its analysis that can indicate system changes. ...Successful changes are promoted to encourage continuous improvement in overall performance outcomes throughout the organization. Successful changes are embedded into operating procedure, which become performance standards and guidelines for best practice. ...Purpose The performance improvement efforts ensure a functional design for a process that supports systematic monitoring, analysis, and improvement of performance and risk elements with respect to patient outcome. ... Essential Processess Improvements in organizational performance and risk management are based on essential processes. These processes include the designs for care and service systems, data collection from ongoing monitors and reports, analysis of performance at milestones of functional operation, analysis of risk at milestones of functional operation, and compliance with improvements indicated by sustained performance results. Performance improvement are based on a practical 'doing the right thing and doing the right thing well' approach focusing on how the systems allow for less than standard outcome. ...Goals and Objectives ...To preserve the safety of patients involved in treatment at (Name of Hospital) and to monitor identified performance improvement issues that may affect the patient...the following objectives have been approved: 1. To endeavor to meet all state, federal regulatory and accreditation patient safety standards. 2. To investigate, categorize and analyze all patient safety occurrences or variances that could cause an unfavorable outcome. These include...policy and procedure errors, boundary violations, safety and security concerns...3. To proactively develop patient safety priorities based on data analysis. 4. Incorporate successful processes that may increase patient safety. 5. Educate the staff on patient safety issues. 6. To collect, aggregate and analyze data on important processes on a monthly basis. ...".

Interview on 07/31/2012 at 1350 with administrative management staff revealed an incident involving a 13 year-old female (Patient #9) and a 17 year-old male (Patient #8) occurred on 03/24/2012. Interview revealed the 13 year-old reported she had consensual sexual relations with the 17 year-old male while both were patients on the 2 West, adolescent unit, of the hospital. Interview further revealed the actions implemented after investigating this incident included housing adolescents according to age groups, with the goal being no more than a 3 year age group difference on any adolescent unit and retraining the staff of the adolescent units (2 East and 2 West) to activate the motion detection system during the nighttime hours. Interview revealed the motion detectors were functional but were not activated at the time of the 03/24/2012 incident. Further interview revealed a second incident was reported to the adolescent nursing staff on 07/17/2012 by a 12 year-old male (Patient #3) related to inappropriate sexual relations with a 13 year-old male (Patient #4). Interview revealed this incident allegedly took place on 07/15/2012 on 2 North A. Interview revealed the adolescent unit had been relocated from 2 West to 2 North A on 06/28/2012. Interview further revealed the investigation revealed the 15 minute observation check on 07/15/2012 on 2 North A was not completed at 2200 per hospital policy and the mental health technician (MHT #1) assigned to complete the check was terminated. Further interview revealed the motion detection system was not activated on 07/15/2012 on 2 North A. Interview revealed, "the staff told us they didn't think about it (motion detection system) when they changed units". Interview further revealed a motion detection laserbeam curtain to detect motion in and out of the bedroom door was placed at the door threshold of Room 414 on 07/20/2012 to use for adolescent patients with known sexual misconduct. Interview further revealed the adolescent unit was moved to 2 North B on 07/23/2012, a unit without a room with a motion detection laserbeam curtain for use with adolescents with known sexual misconduct. Further interview revealed an attestation statement by the registered nurse was added to the 15 minute observation check sheet to affirm the every 15 minute observations by the mental health technicians were completed. Further interview revealed the third shift (0000-0800) house supervisor is monitoring the activation of the motion detection system nightly, effective 07/24/2012.

Review of a hospital document presented to the surveyor 08/02/2012, "Overview of Trainings and Actions regarding March 24th and July 15th Incidents", revealed, "As a result of the March 24th incident: Implemented a new policy and procedure for the expectations of the use of the motion detection system. Provided a copy of the new policy to all RNs (registered nurses) and MHTs (mental health technicians). The policy was verbally reviewed with staff and they were asked to sign an attestation acknowledging responsibility for following the procedure outlined in the policy. For prn (as needed) staff that work sporadically, the policy and attestation were mailed to their home on 04/20/2012 for self-study. All motion detectors were tested by the maintenance department to ensure they were functioning properly. Staff identified that the placement of the computer monitor for video review was in an inconvenient location. The monitor was moved to allow for clearer access. As a result of the July 15th incident: Issue #1: Identified that the motion detections system was not in use at the time of the incident. Actions: 1. Revised the motion detection policy to more broadly speak to the use of the motion detection system on all units where patients under the age of 18 are sleeping. a. All FT (full time) clinical staff will sign attestations acknowledging receipt of the policy and understanding of the content by Monday 08/06/2012 (23 days after the latest incident on 07/15/2012). b. FT staff received face to face verbal instructions regarding the new policy. Training was either in a small group or one to one meeting. ...Start date for trainings was 07/19/2012 and ongoing. PRN staff that were not available for face to face training had a self-study packet mailed to their home on 07/23/12 with the expectation that they would return the attestation on their next scheduled shift. c. Compliance will be monitored through the use of the 3rd Shift Monitoring Tool. The 3rd shift House supervisor will ensure all units have the system in operation. Any issue with non-compliance will be routed to the appropriate ADON (Assistant Director of Nursing). Started 07/25/2012. 2. Discussed the addition of an additional layer of security to be utilized with patients that are identified as high risk for sexual acting out behaviors. a. A temporary room "door curtain" was installed in the room of the alleged victim on 07/20/2012. The system emits an audible tone if anyone enters or exits the room. b. A permanent "door curtain" will be hardwired on Monday 07/23/12. c. One room per unit will be identified for installation of an electronic "door curtain". This system can be turned off and on as clinically indicated. To be completed by 8/3/2012. Issue #2. Lapse in procedure for 15 minute observations rounds. Actions: 1. Implemented an updated 15 minute observation round sheet at midnight on Friday 7/20/12. a. The new form adds a requirement that the RN monitors/supervises the completion of the 15 minute observation rounds and signs an attestation on the check sheet once per shift. b. Monitoring component is under development with target implementation date of 8/3."

Review on 08/01/2012 of current hospital policy "Level of Observation and Special Precautions" Policy Number: CS61 (date issued 06/98; last date reviewed 08/11) revealed "POLICY All patients will be routinely observed in compliance with physician orders and prescribed protocols. ...c. Observation on an every 15 minute frequency. ...This is the minimal level of observation and all patients are on 15 minute frequency observation on all three shifts. ...13. Routine or Unit Precautions The Charge Nurse shall assign staff to perform routine observations on a designated set of patients. a. ...The Charge Nurse shall arrange for assigned staff to be relieved for breaks and meals, as necessary. ...e. All patients receive a minimum of 15 minute's observation. ..."

Review revealed documentation of a "MEMORANDUM" (MEMO #2 regarding Motion Detectors) to RNs, MHTs, Social Services Staff, and Physicians from the Chief Nursing Officer and Director of Risk Management/Performance Improvement dated 07/19/2012, reference "Motion Detectors: Youth Services" revealed "By signing this form I am acknowledging that I have received a copy of the (Hospital A name) policy and procedure: Motion Detectors, Youth Services. I further acknowledge that I am responsible for following the procedure outlined in these polices. I also acknowledge that I have received a copy of the updated precaution record to be used in documentation of 15 minute observation rounds. I understand the expectation that the charge RN on the unit is responsible for reviewing the rounds a minimum of once per shift, and documenting on the precaution record."

1. Open record review of Patient #14 revealed a 13 year-old male, admitted 07/23/2012 with cyclothymia and post-traumatic stress disorder. Review of the 15 minute observation documentation record revealed no RN signature on the following shifts: 07/27/2012 from 0000 until 0800, 07/28/2012 from 0000 until 0800, 07/29/2012 from 0000 until 0800. Record review revealed RN # 5 was the charge nurse on 07/27/2012 from 0000 until 0800 and RN #8 was the charge nurse on 07/28/2012 and 07/29/2012 from 0000 until 0800.

Review of the personnel files revealed RN #5 signed the attestation on 07/20/2012 acknowledging the charge nurse's responsibility to ensure 15 minute observation rounds. Review further revealed RN #8 signed the attestation on 07/21/2012 acknowledging the charge nurse's responsibility to ensure 15 minute observation rounds.

Interview on 07/31/2012 at 1330 with administrative management staff revealed the RN should sign all 15 minute observation documentation records at mid-shift to attest their oversight of the mental health technicians completing the 15 minute observation checks. Interview confirmed no RN signature/verification for Patient #14 on the following shifts: 07/27/2012 from 0000 until 0800, 07/28/2012 from 0000 until 0800, 07/29/2012 from 0000 until 0800.

Telephone Interview on 08/01/2012 at 1600 with RN # 5 revealed, "as the RN, I oversee the 15 minute checks. I make sure they (mental health technicians) are checking on patients by going into their rooms and making sure they are breathing. I am supposed to sign off on the 15 minute check sheets at mid-shift and check it again at the end of the shift".

2. Open record review of Patient #21 revealed a 13 year-old male, admitted 07/17/2012 to the latency unit. Review of the 15 minute observation documentation record revealed no RN signature on the following shifts: 07/22/2012 from 0800 until 1600, 07/27/2012 from 0000 until 0800, 07/28/2012 from 0000 until 0800 and 7/29/2012 from 0000 until 0800.

Review of staffing review RN #2 was assigned to Patient #21 on 07/22/2012 from 0800 until 1600 and RN #5 was assigned to the patient on 07/27/2012 from 0000 until 0800. Review revealed RN #8 was assigned to Patient #21 on 07/28/2012 from 0000 until 0800 and 07/29/2012 from 0000 until 0800.

Review of the personnel files revealed RN #2 signed the attestation on 07/21/2012 acknowledging the charge nurse's responsibility to ensure 15 minute observation rounds. Review revealed RN #5 signed the attestation statement on 07/21/2012. Review further revealed RN #8 signed the attestation on 07/21/2012 acknowledging the charge nurse's responsibility to ensure 15 minute observation rounds.

Interview on 07/31/2012 at 1330 with administrative management staff revealed the RN should sign all 15 minute observation documentation records at mid-shift to attest their oversight of the mental health technicians completing the 15 minute observation checks. Interview confirmed no RN signature/verification for Patient #19 on the following shifts: 07/22/2012 from 0800 until 1600, 07/27/2012 from 0000 until 0800, 07/28/2012 from 0000 until 0800 and 07/29/2012 from 0000 until 0800.

Telephone interview on 08/01/2012 at 1600 with RN #5 revealed, "as the RN, I oversee the 15 minute checks. I make sure they (mental health technicians) are checking on patients by going into their rooms and making sure they are breathing. I am supposed to sign off on the 15 minute check sheets at mid-shift and check it again at the end of the shift".

3. Open record review of Patient #19 revealed a 12 year-old female, admitted 07/11/2012 to the latency unit. Review of the 15 minute observation documentation record revealed no RN signature on 07/22/2012 from 1600 until 0000.

Review of staffing review RN #9 was assigned to Patient #19 on 07/22/2012 from 1600 until 0000.

Review of the personnel files revealed RN #9 signed the attestation on 07/21/2012 acknowledging the charge nurse's responsibility to ensure 15 minute observation rounds.

Interview on 07/31/2012 at 1330 with administrative management staff revealed the RN should sign all 15 minute observation documentation records at mid-shift to attest their oversight of the mental health technicians completing the 15 minute observation checks. Interview confirmed no RN signature/verification for Patient #19 on 07/22/2012 from 1600 until 0000.

Telephone interview on 08/01/2012 at 1600 with RN #5 revealed, "as the RN, I oversee the 15 minute checks. I make sure they (mental health technicians) are checking on patients by going into their rooms and making sure they are breathing. I am supposed to sign off on the 15 minute check sheets at mid-shift and check it again at the end of the shift".

Observation during tour of the latency unit on 07/31/2012 at 1540 revealed a census of 8 patients. Review of the medical records of the 8 current patients revealed 15 minute observation documentation records were not signed by RN staff as required for 3 of the 8 patients. Interview with administrative management staff during tour revealed there was no monitor in place to review compliance with this new procedure.

Review of the hospital policy, "Motion Detectors: Adolescent Services", effective 03/27/2012 revealed, "Policy It is the policy of (Name of Hospital) that motion detectors are to be in operation while adolescent patients on 2 East and 2 West are scheduled to be in their rooms, particularly from the hours of 10:00 PM until 7:00 AM. It is the responsibility of the charge nurse on the unit (or designee) to check and ensure that the motion detectors are functioning appropriately during the times specified in this policy. Procedure 1. The motion detectors are to be activated once all patients are in their assigned rooms for bedtime. ...The motion detectors are to be deactivated when staff begins the process of waking patients up in the morning. ...2. Staff should not disable the system at any point once patients have gone to bed for the evening. ...".

Review of a memorandum dated 03/27/2012 to all nursing staff from the Chief Nursing Officer and the Director of Risk Management and Performance Improvement revealed, "...By signing this form I am acknowledging that I have received a copy of the (Name of Hospital) policy and procedure: Motion Detectors, Adolescent Services. I further acknowledge that I am responsible for following the procedure outlined in these policies". Review of the memorandum revealed a line for the employee's printed name, signature and date.

Review of the hospital's nursing staff roster (including nurses and mental health technicians) with completion of the attestation statements for utilization of the motion detectors on the adolescent services units revealed 129 of 186 (69%) nursing staff completed and returned the attestation statement dated 03/27/2012 related to motion detectors on the adolescent services units. Further review on 08/02/2012 of the roster revealed that after retraining on the policy on 07/19/2012, 44% of the PRN (as needed staff) had completed the attestation statement, 86% of the regular nursing staff have completed and 93% of the adolescent staff have completed the statement.

Personnel file review on 08/02/2012 for RN #1 revealed a date of hire of 06/07/2010. Review revealed the RN was a "PRN (as needed)" staff member. Review revealed RN#1 was currently employed by Hospital A. Review of a "MEMORANDUM" (MEMO #1 regarding Motion Detectors) to nursing staff from the Chief Nursing Officer and Director of Risk Management/Performance Improvement dated 03/27/2012, reference "Motion Detectors: Adolescent Services" revealed "By signing this form I am acknowledging that I have received a copy of the (Hospital A name) policy and procedure: Motion Detectors, Adolescent Services. I further acknowledge that I am responsible for following the procedure outlined in these polices." Further review revealed the hand written signature of RN #1 dated 04/26/2012 on the form. Continued personnel file review failed to reveal documentation RN #1 received re-education and signed the attestation form for the "Memorandum" dated 07/19/2012 (MEMO #2 for Motion Detectors) from the CNO and Director of RM/PI.

Review on 08/02/2012 of a "Time Card Report" from 03/04/2012 to 08/04/2012 for RN #1 (the charge nurse assigned to Patient's #3 and #4 during the alleged incident on 07/15/2012) revealed RN #1 has worked three (3) shifts (07/22/2012, 07/26/2012, and 07/27/2012) after the alleged incident on 07/15/2012 involving Patient #3 and Patient #4 and the implementation of the Memorandum dated July 19, 2012.

Interview on 08/02/2012 at 1330 with the Director of RM/PI confirmed that RN #1 was the nurse assigned to Patients' #3 and #4 during the alleged incident on 07/15/2012. Interview revealed she was unable to locate RN #1's signed attestation form regarding the revised policy and motion detector training (MEMO #2) dated July 19, 2012 as of 08/02/2012.

Review of an e-mail sent to house supervisors from the CNO, dated 07/24/2012, revealed, "...can you please institute this audit tool as you make your rounds? We need to implement based on the new policy we put into place...".

Review of the 3rd shift House supervisor monitoring tool, implemented 07/25/2012, revealed the house supervisors are to ensure the motion detection system is activated on the adolescent patient units.

Review of the 3rd shift House supervisor monitoring tools, implemented on 07/25/2012, revealed no documentation that the 3rd shift house supervisor checked the motion detection system on the adolescent patient units on 07/29/2012, 07/30/2012 and 07/31/2012.

Interview on 08/02/2012 at 0935 with administrative staff revealed, "there was a problem" with the monitoring. Interview revealed, "one of the house supervisors did not realize the new process was to start immediately (ensuring the motion detection system was activated on the adolescent patient units). She thought it started August 1st. That house supervisor is PRN (as needed). The e-mail was sent to them on July 25th and it was to start immediately".

Interview on 08/02/2012 at 0005 with a third shift house supervisor revealed she was a prn staff member that was coming on duty. Interview revealed the staff member had worked on 07/29/2012 and 07/30/2012. The nurse stated "We have a new sheet that we just started, an audit that started August 1. I have not used the tool yet. I worked Sunday and Monday as house supervisor. I did not complete the audit tool then." The nurse further stated she had received an attestation statement with a new policy attached in the mail. The nurse had her attestation statement with her and stated she planned to turn her attestation in the next morning. She stated "I didn't turn it in on Sunday before I worked. I just remembered it today."

Consequently, an incident involving two adolescents (Patients #8 and 9) related to inappropriate sexual activity occurred on 03/24/2012. The hospital put an action plan into place on 03/27/2012 related to activation of the motion detection system on the adolescent units with the directive that the charge nurse be responsible for ensuring the motion detection system activation beginning at 2200 until 0700 on all adolescent patient units. The hospital failed to ensure all staff were trained on the new policy regarding the motion detection system activation. There was no monitoring of the action taken after the incident on 03/24/2012. A second incident involving two adolescent males (Patients #3 and #4) occurred on 07/15/2012 involving alleged rape. The hospital investigation identified the 15-minute observation rounds were not completed per policy for Patients #3 and #4 on 07/15/2012 and the motion detection system was not activated on the night of 07/15/2012. As of 08/02/2012, the hospital has had no formal re-training of the 15-minute observation rounds. The hospital re-trained staff on the motion detection system beginning 07/19/2012 and as of 08/02/2012; 44% of the PRN (as needed staff), 86% of the regular nursing staff, and 93% of the adolescent staff have completed the attestation statements. As of 08/02/2012, the monitoring of the 15-minute observation rounds and the third shift supervisor monitoring tool was inconsistent.

Based on hospital policy reviews, medical record reviews, video surveillance footage reviews, daily staffing assignment sheet reviews, personnel file reviews, job description reviews, memorandum reviews, time card report reviews, and staff interviews the hospital's nursing staff failed to: A) supervise, monitor, and implement patient safety measures for patients on 1 of 2 adolescent units; B)document supervision of every 15 minute observation checks according to policy for 3 of 8 records reviewed (#14, #21, #19); and C) failed to ensure a physician's order was completed for 1 of 1 consultation order reviewed (#6).

The findings include:

A) Review on 08/01/2012 of current hospital policy "Level of Observation and Special Precautions" Policy Number: CS61 (date issued 06/98; last date reviewed 08/11) revealed "POLICY All patients will be routinely observed in compliance with physician orders and prescribed protocols. ...c. Observation on an every 15 minute frequency. ...This is the minimal level of observation and all patients are on 15 minute frequency observation on all three shifts. ...13. Routine or Unit Precautions The Charge Nurse shall assign staff to perform routine observations on a designated set of patients. a. ...The Charge Nurse shall arrange for assigned staff to be relieved for breaks and meals, as necessary. ...e. All patients receive a minimum of 15 minute's observation. ...f. Patient sleep/bed checks should be conducted carefully as follows: i. Staff should document a patient's presence at bed check only after actual observation and identification of the patient. ii. When a patient appears to be resting or asleep, staff should observe for the rise and fall of the patient's chest to assure he/she is breathing without difficulty and is not in any distress. ..."

Review on 08/01/2012 of current hospital policy "Patient Sexual Familiarity Prevention Guidelines" Policy Number: CS64 (date issued: 06/98; last date reviewed 04/12) revealed "POLICY ....staff should take steps to guard against sexual familiarity between patients during their hospital stay. Prevention ...4. Unit staff should conduct frequent rounds of the halls and patient rooms to establish the patients' safety and monitor their behavior. Nursing staff should monitor the halls during the day and at night ...Environmental Considerations The patient care environment should be evaluated on an ongoing basis to identify situations that may contribute to sexual acting out behavior between patients. ...3. Staff should try to have visualization of the patient care halls at times when any patients are not occupied in groups and activities. This may include....motion detectors, ....or staff members posted in the halls when the patients are not involved in group therapeutic activities. ...it can be important, particularly with adolescents and children, not to leave the halls unattended. ..."

Review on 08/01/2012 of hospital policy "Motion Detectors: Adolescent Services" Policy Number [none] (Original Date: 03/27/12) in effect on 07/15/2012 revealed "Policy It is the policy of (Hospital Name) that motion detectors are to be in operation while adolescent patients on 2 East and 2 West are scheduled to be in their rooms, particularly from the hours of 10:00 PM until 7:00 AM. It is the responsibility of the charge nurse on the unit (or designee) to check and ensure that the motion detectors are functioning appropriately during the times specified in this policy. Procedure 1. The motion detectors are to be activated once all patients are in their assigned rooms for bedtime. ...The motion detectors are to be deactivated when staff begins the process of waking patients up in the morning. ...2. Staff should not disable the system at any point once patients have gone to bed for the evening. ..."

1. Closed medical record review on 07/31/2012 for Patient #3 revealed a 12 year old male admitted voluntarily to Hospital A on 06/25/2012 and was discharged on 07/23/2012 with a diagnosis of post-traumatic stress disorder and reactive attachment disorder. Record review revealed the patient was placed on 2 East (an adolescent unit) upon admission and was subsequently transferred on 06/28/2012 to 2 North A (an adolescent unit). Further review revealed while hospitalized Patient #3 reported to staff on 07/17/2012 at 1530 that Patient #4 allegedly initiated inappropriate sexual relations with him while in his room. Review of a "Physician's Orders (Admission)" form dated 06/25/2012 at 1745 revealed a telephone order obtained by a Registered Nurse (RN) to place Patient #3 on "Every 15 minute check".

2. Closed medical record review on 08/01/2012 for Patient #4 revealed a 13 year old male admitted under involuntary commitment to Hospital A on 07/14/2012 and was discharged on 07/23/2012 with a diagnosis of Cyclothymia and borderline intellectual functioning. Record review revealed the patient was placed on 2 North A (an adolescent unit) upon admission and subsequently transferred to 2 North B (an adolescent unit) on 07/17/2012. Further review revealed while hospitalized Patient #4 was accused by Patient #3 of allegedly initiating inappropriate sexual relations with him in his room on or about 07/15/2012. Patient #3 reported the incident to nursing staff on 07/17/2012 at 1530 (2 days later). Review of a "Physician's Orders (Admission)" form dated 07/14/2012 at 2340 revealed a telephone order obtained by a Registered Nurse (RN) to place Patient #4 on "Every 15 minute check".

Review on 08/01/2012 at 1450 of video surveillance footage from camera [12] 2N-E.Rm12-27 on the 2 North A (adolescent unit) from 07/15/2012 at 2107 to 07/15/2012 at 2258 revealed the following observations:
~2110 - Mental Health Technician (MHT) #1 observed walking down hallway away from camera (performing Q15 minute checks) and returning exiting camera view (Q15 minute check completed).
~2113 - Patient #4 observed out of room in hallway.
~2115 - Patient #3 and Patient #4 observed out of rooms in hallway.
~2116 - Patient #4 observed returning to his room located on right side (camera view) of hallway.
~2117 - Patient #3 observed going to Patient #4's doorway then returns back to his room (diagonally across hallway from Patient #4's room) on the left side (camera view) of hallway.
~2118 - MHT #1 observed entering camera view and walking down hallway away from camera. Observed looking into Patient #3 and #4's room. Returned and exited camera view (Q15 minute check complete).
~2119 - RN #1 observed entering camera view and walking down hallway away from camera. Returns and exits camera view.
~2130 - Patient #4 observed out in hallway and returns to room.
~2130 - Observed hall lights turned off for bedtime hours.
~2132 - Patient #3 observed out in hallway and returns to room.
~2132 - MHT #1 observed entering camera view and walking down hallway away from camera and returns (Q15 minute check complete).
~2133 - Patient #3 observed peering out doorway of room into hallway looking towards nursing station.
~2141 - MHT #1 observed entering camera view walks down hallway away from camera. MHT #1 observed looking into Patient #3's room and then going across hallway and looking into Patient #4's room. MHT continues down hallway and then returns out of camera view (Q15 minute check completed).
~21:47:31 - Patient #3 observed exiting room into hallway and walks towards nursing station out of camera view wearing a tee-shirt and shorts.
~21:48:01 - Patient #3 observed entering camera view walks down hallway and enters his room.
~21:55:04 - Patient #4 observed exiting room and runs across hallway into Patient #3's room wearing a shirt and pants.
NOTE: Q15 minute check due at 2156 [2200], Not completed..
~22:01:14 - Patient #4 observed exiting Patient #3's room (6 minutes later) and runs across hallway into his room wearing a shirt and pants.
~22:09:13 - Patient #4 observed exiting room and runs out into hallway wearing a patient gown, stops midway of hall and returns back to his room.
~22:09:27 - Patient #4 observed existing his room and runs across hallway wearing a patient gown and enters Patient #3's room.
~22:22:43 - MHT #1 observed entering camera view and walking down hallway (performing Q15 minute checks).
NOTE: Last Q15 minute check was performed at 2141 [forty-one (41) minutes prior].
~22:22:57 - MHT #1 observed looking into Patient #3's room from doorway. (Patient #4 is present in Patient #3's room while MHT #1 performs Q15 minute check).
~22:23:00 - MHT #1 observed crossing hallway and looking into Patient #4's room from doorway.
~22:23:22 - MHT #1 observed leaving doorway of Patient #4 room and walking down hallway away from camera.
~22:23:33 - Patient #3 observed exiting room into hallway wearing tee-shirt and shorts. (Patient #4 still present in Patient #3's room) MHT #1 observed walking from distal end of hallway back towards nursing station. Patient #3 observed stopping midway hall facing MHT #1 and makes hand gestures.
~22:23:46 MHT #1 observed entering Patient #4's room and turns light on, Patient #3 is still in hallway and begins to walk towards nursing station and out of camera view.
~22:23:55 - MHT #1 observed exiting Patient #4's room and walks back towards nursing station out of camera view.
~22:24:21 - Patient #3 observed walking down hallway.
~22:24:24 - Patient #3 observed entering his room.
~22:24:36 - Patient #4 observed exiting Patient #3's room wearing a patient gown and running across hallway (15 minutes after entering Patient #3's room).
~22:24:38 - Patient #4 observed entering his room.
~22:25:25 - MHT #1 observed exiting dayroom/classroom on right side of hallway (camera view) and walking down hallway away from camera and entering Patient #4' room.
~22:25:35 - Observed lights turn on in Patient #4's room.
~22:25:36 - MHT #1 observed exiting Patient #4's room and walks down hallway away from camera.
~22:26:37 - MHT #1 observed returning from down hallway entering dayroom/classroom on right side of hallway out of camera view.
~22:32:24 - Patient #3 observed exiting his room in a patient gown and crossing hallway into Patient #4's room then returns to his room.
~22:34:25 - MHT #1 observed walking down hallway away from camera.
~22:34:40 - MHT #1 observed looking into Patient #3's room.
~22:34:43 - MHT #1 observed crossing hallway and entered into Patient #4's room.
~22:34:54 - MHT #1 observed exiting Patient #4 room and walking down hallway away from camera and returning out of camera view.
~22:36:42 - Patient #3 observed exiting room into hallway wearing patient gown.
~22:36:46 - Patient #3 observed entering Patient #4's room.
~22:36:50 - Patient #3 observed exiting Patient #4's room and running across hallway to his room.
~22:37:01 - MHT #1 observed walking down hallway away from camera and entering Patient #4's room.
~22:37:06 - RN #1 observed walking down hallway away from camera to doorway of Patient #3's room.
~22:37:09 - MHT #1 observed exiting Patient #4's room and walking across hallway and entering Patient #3's room.
~22:37:36 - MHT #1 observed exiting Patient #3's room. RN #1 and MHT #1 walk down hallway towards nursing station out of camera view.
~22:58:13 - RN #1 observed walking down hallway (performing Q15 minute checks) and returning out of camera view.

Continued record review on 08/01/2012 revealed "Precautions Record" forms from 06/25/2012 (at time of admission to unit) to 07/23/2012 (at time of discharge) for Patient #3. Review revealed documentation by a RN or MHT of "checks" being performed every 15 minutes. Further review revealed on 07/15/2012 (date of alleged rape) documentation by MHT #1 of a Q15 minute check being performed at 2200 for Patient #3 with a documented behavior of "2" (lying or sitting) and a location "R" (in patient's room). Review of video surveillance footage confirmed a Q15 minute check was not performed at 2200 as documented in the medical record by MHT #1.

Continued record review on 08/01/2012 revealed "Precautions Record" forms from 07/14/2012 (at time of admission to unit) to 07/23/2012 (at time of discharge) for Patient #4. Review revealed documentation by a RN or MHT of "checks" being performed every 15 minutes. Further review revealed on 07/15/2012 documentation by MHT #1 of a Q15 minute check being performed at 2200 for Patient #4 with a documented behavior of "2" (lying or sitting) and a location "R" (in patient's room). Review of video surveillance footage review confirmed a Q15 minute check was not conducted as documented in the medical record by MHT #1. Further review revealed documentation by MHT #1 of a Q15 minute check being performed at 2215 for Patient #4 with a documented behavior of "2" (lying or sitting) and a location "R" (in patient's room). Review of video surveillance footage revealed Patient #4 entered Patient #3's room at 2209 and exited at 2224 (15 minutes later). Review confirmed Patient #4 was not in his room at 2215 as documented in the medical record by MHT #1.

Summarily, video surveillance footage review revealed the nursing staff failed to conduct Q15 minute observations per policy resulting in a 41 minute lapse of supervision on 07/15/2012 from 2141 to 2222. Review confirmed a Q15 minute check was not performed at or about 2156 [2200] by nursing staff. Review confirmed Patient #3 and #4 were alone in Patient #3's room from 2155 to 2201 (6 minutes) and from 2224 to 2209 (15 minutes) unsupervised. Further review revealed MHT #1 failed to identify the presence of Patient #4 in Patient #3's room at the time the Q15 minute check was performed at 2223 [2215]. In addition the video surveillance footage review confirmed the Q15 minute checks documented on the "Precautions Record by MHT #1 for Patient #3 on 07/15/2012 at 2200 and Patient #4 on 07/15/2012 at 2200 and 2215 were inaccurate.

Review of the daily staffing/assignment sheet for "Sunday - 2nd Shift" dated 07/15/2012 revealed RN #1 was assigned to 2 North A (adolescent unit) as the Charge Nurse and MHT #1 was assigned to the unit as the mental health technician.

Telephone Interview on 08/01/2012 at 1400 with RN #1 revealed she was on duty 07/15/2012 during the evening shift (1600 to 0030), assigned to 2 North A. Interview revealed she was the charge nurse on the unit. Interview revealed she was the only RN on-duty for the 2 North A unit. Interview revealed MHT #1 was the MHT on duty with her. Interview revealed "we work as a team." Interview revealed "we are all responsible" for making sure patient care is done. Interview revealed the charge nurse is not responsible for supervision of the MHTs. Interview revealed "I am not their supervisor, there is a supervisor over me." Interview revealed RN #1 makes out the assignments and it is "up to the MHT to carry out their assignment." Interview revealed "I am there to make sure patient safety and care is performed." Interview revealed "if the MHT can't carry out the assignment they are suppose to notify me and the nursing supervisor is notified." Interview revealed "I do not know when they (MHTs) are not carrying out their assignments." Interview revealed "If I don't see a problem, I don't know it." Interview revealed the 2 North A unit uses motion detectors at night. Interview revealed she is familiar with the motion detectors on the unit. Interview revealed it is the MHT who is responsible for turning the motion detectors on at bedtime. Interview revealed "I was educated on the policy but do not recall reading a policy or signing any attestation." Interview revealed she was unaware the policy identified the charge nurse or the charge nurse's designee for being responsible for ensuring the motion detectors were activated. Interview revealed "I was not shown a policy." Interview revealed she does not recall if the motion detectors were turned on at bedtime on the evening of 07/15/2012. Interview revealed she remembers being at the nursing station when she saw one patient go into another patient's room. Interview revealed she went to the room to check on the patients. Interview revealed she told the patients it was inappropriate and to return to their room. Interview revealed she does not recall if the motion detector alarmed when the patients went into the hallway. Interview revealed she did not check to see if the motion detectors was active or working. Interview revealed she was unaware MHT #1 failed to conduct a Q15 minute check at 2200 on 07/15/2012. Interview revealed she was unaware a check had not been performed for 41 minutes. Interview revealed "all of us are responsible for making sure Q15 minutes checks are done." Interview revealed she does not "look at the sheets to see if the MHT is doing checks." Interview revealed "I do not walk behind the MHTs." Interview revealed "when we are not out there we do not see them." Interview revealed she was made aware of Patient #3's allegations when "upper management" notified her and questioned her. Interview revealed she did not recall when management questioned her regarding the incident.

Interview on 08/01/2012 at 2245 with RN #4 revealed she was the charge nurse for the 2 North B (Latency) unit for second shift. Interview revealed she had received recent education and training regarding the policy and use of motion detectors on the unit. Interview revealed as the charge nurse she was responsible for ensuring the motion detectors were activated at bedtime and/or for delegating the task to the MHT. Interview revealed she is responsible for reviewing the documentation of Q15 minute checks by the MHT to ensure they were completed and then initialing the forms once per shift. Interview revealed she was responsible for supervising the MHTs during her assigned shift.

Interview on 08/01/2012 at 2315 with RN #3 revealed she was the charge nurse for the 2 East (Adolescent) unit for second shift. Interview revealed she had received recent education and training regarding the policy and use of motion detectors on the unit. Interview revealed as the charge nurse she was responsible for ensuring the motion detectors were activated at bedtime and/or for delegating the task to the MHT. Interview revealed she is responsible for reviewing the documentation of Q15 minute checks by the MHT to ensure they were completed and then initialing the forms once per shift. Interview revealed she was responsible for supervising the MHTs during her assigned shift.

Interview on 07/31/2012 at 1346 with administrative management staff revealed MHT #1 was unavailable for interview during survey. Interview revealed MHT #1 had been terminated from employment at the hospital.

Personnel file review on 08/02/2012 for MHT #1 revealed a date of hire of 08/29/2011. Review revealed the MHT was a full-time staff member. Review revealed MHT #1 was terminated from employment at Hospital A on 07/20/2012. Review of a handwritten statement signed by MHT #1 (not dated) revealed "On Sunday July 15 2012 I (MHT #1 name) was working on the unit 2nd shift. At no point during the shift did I see (Patient #3 name) in (Patient #4 name) room or (Patient #4 name) in (Patient #3 name) room. During one of my rounds upon opening the door to (Patient #4 name) room I did not see him. I checked around the unit returned to his room for a second look and saw him....I told him to get in the bed....Also during the shift the nurse (RN #1) and I walked down to their rooms and explained to them that they needed [to] stay in their rooms [and] go to sleep. Upon reviewing the video I am upset that I was unable to prevent the 2 boys from going into each others room and preventing this situation from happening." File review revealed documentation of a "MEMORANDUM" (MEMO #1 regarding Motion Detectors) to nursing staff from the Chief Nursing Officer (CNO) and Director of Risk Management/Performance Improvement (RM/PI) dated 03/27/2012, reference "Motion Detectors: Adolescent Services" revealed "By signing this form I am acknowledging that I have received a copy of the (Hospital A name) policy and procedure: Motion Detectors, Adolescent Services. I further acknowledge that I am responsible for following the procedure outlined in these polices." Further review revealed the hand written signature of MHT #1 dated 04/02/2012 on the form. File review revealed documentation of a "MEMORANDUM" (MEMO #2 regarding Motion Detectors) to RNs, MHTs, Social Services Staff, and Physicians from the Chief Nursing Officer and Director of Risk Management/Performance Improvement dated 07/19/2012, reference "Motion Detectors: Youth Services" revealed "By signing this form I am acknowledging that I have received a copy of the (Hospital A name) policy and procedure: Motion Detectors, Youth Services. I further acknowledge that I am responsible for following the procedure outlined in these polices. I also acknowledge that I have received a copy of the updated precaution record to be used in documentation of 15 minute observation rounds. I understand the expectation that the charge RN on the unit is responsible for reviewing the rounds a minimum of once per shift, and documenting on the precaution record." Further review revealed the hand written signature of MHT #1 dated 07/19/2012 on the form. File review revealed documentation of a form entitled "Important Points to Remember - 15 minute checks" with the following documented on the form "To be done correctly, 15 minute checks must: *Be documented when they are done and never documented ahead of time or documented in a manner to fill in previously done checks....*Be done by actually seeing the patient in the location documented on the form....A special reminder to nurses: *Unit nurses are responsible for assigning staff to do 15 minute checks and then ensuring the checks are being done. My signature attests that I have received this memo and understand the performance expectations regarding 15 minute checks." Review revealed the hand written signature of MHT #1 on the form dated 09/01/2011.

Personnel file review on 08/02/2012 for RN #1 revealed a date of hire of 06/07/2010. Review revealed the RN was a "PRN (as needed)" staff member. Review revealed RN#1 was currently employed by Hospital A. Review of a current job description and performance evaluation form signed and dated 07/02/2011 RN #1 revealed "...Supervises: Mental Health Technicians....as assigned per shift. ..." Further review revealed "Position Summary: ...Provide medical management and assessment of patients. Ensure environmental safety and crisis management for the patient population. ...Make patient & task assignments to subordinates & monitor their performance of duties. ...Document patient care, ensure that data is accurate,..." Review of a "MEMORANDUM" (MEMO #1 regarding Motion Detectors) to nursing staff from the Chief Nursing Officer and Director of Risk Management/Performance Improvement dated 03/27/2012, reference "Motion Detectors: Adolescent Services" revealed "By signing this form I am acknowledging that I have received a copy of the (Hospital A name) policy and procedure: Motion Detectors, Adolescent Services. I further acknowledge that I am responsible for following the procedure outlined in these polices." Further review revealed the hand written signature of RN #1 dated 04/26/2012 on the form.

Interview on 07/31/2012 at 1350 with administrative management staff revealed as a result of an incident that occurred on 03/24/2012 on the 2 West, adolescent unit involving a 13 year-old female (Patient #9) and a 17 year-old male (Patient #8) having consensual sexual relations with each other, revealed the actions implemented after investigating the incident included housing adolescents according to age groups, with the goal being no more than a 3 year age group difference on any adolescent unit and retraining the staff of the adolescent units (2 East and 2 West) to activate the motion detection system during the nighttime hours. Interview revealed the motion detectors were functional but were not activated at the time of the 03/24/2012 incident. Further interview revealed an incident was reported to the adolescent unit nursing staff on 07/17/2012 by a 12 year-old male (Patient #3) related to inappropriate sexual relations with a 13 year-old male (Patient #4). Interview revealed this incident allegedly took place on 07/15/2012 on the 2 North A adolescent unit. Interview revealed the adolescent unit had been relocated from 2 West to 2 North A on 06/28/2012. Interview revealed the investigation of the incident on 07/15/2012 revealed the 15 minute observation checks performed on 07/15/2012 on the 2 North A unit was not completed at 2200 per hospital policy and the mental health technician (MHT #1) assigned to complete the checks was terminated. Further interview revealed the motion detection system was not activated on 07/15/2012 on 2 North A. Interview revealed, "the staff told us they didn't think about it (motion detection system) when they changed units" (17 days prior). ...Further interview revealed the motion detector policy was revised and an attestation statement by the registered nurse was added to the 15 minute observation check sheet to affirm the every 15 minute observations by the mental health technicians were completed. Interview revealed the nursing staff was re-educated about the revised motion sensor policy and the staff were required to sign an attestation statement.

Review on 08/02/2012 of a "Time Card Report" from 03/04/2012 to 08/04/2012 for RN #1 revealed RN #1 has worked three (3) shifts (07/22/2012, 07/26/2012, and 07/27/2012) after the alleged incident on 07/15/2012 involving Patient #3 and Patient #4. Continued personnel file review failed to reveal documentation RN #1 received re-education and signed the attestation form for the "Memorandum" dated 07/19/2012 (MEMO #2 for Motion Detectors) from the CNO and Director of RM/PI.

Interview on 08/02/2012 at 1330 with the Director of RM/PI revealed she was unable to locate RN #1's signed attestation form regarding the revised policy and motion detector training (MEMO #2) dated July 19, 2012 as of 08/02/2012.



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B1) Open record review of Patient #14 revealed a 13 year-old male, admitted 07/23/2012 with cyclothymia and post-traumatic stress disorder. Review of the 15 minute observation documentation record revealed no RN signature on the following shifts: 07/27/2012 from 0000 until 0800, 07/28/2012 from 0000 until 0800, 07/29/2012 from 0000 until 0800.

Interview on 07/31/2012 at 1330 with administrative management staff revealed the RN should sign all 15 minute observation documentation records at mid-shift to attest their oversight of the mental health technicians completing the 15 minute observation checks. Interview confirmed no RN signature/verification for Patient #14 on the following shifts: 07/27/2012 from 0000 until 0800, 07/28/2012 from 0000 until 0800, 07/29/2012 from 0000 until 0800.

Telephone Interview on 08/01/2012 at 1600 with RN # 5 revealed, "as the RN, I oversee the 15 minute checks. I make sure they (mental health technicians) are checking on patients by going into their rooms and making sure they are breathing. I am supposed to sign off on the 15 minute check sheets at mid-shift and check it again at the end of the shift".



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B2) Open record review of Patient #21 revealed a 13 year-old male, admitted 07/17/2012 to the latency unit. Review of the 15 minute observation documentation record revealed no RN signature on the following shifts: 07/22/2012 from 0800 until 1600, 07/27/2012 from 0000 until 0800, 07/29/2012 from 0000 until 0800.

Interview on 07/31/2012 at 1330 with administrative management staff revealed the RN should sign all 15 minute observation documentation records at mid-shift to attest their oversight of the mental health technicians completing the 15 minute observation checks. Interview confirmed no RN signature/verification for Patient #19 on the following shifts: 07/22/2012 from 0800 until 1600, 07/27/2012 from 0000 until 0800, 07/29/2012 from 0000 until 0800.

Telephone Interview on 08/01/2012 at 1600 with RN #5 revealed, "as the RN, I oversee the 15 minute checks. I make sure they (mental health technicians) are checking on patients by going into their rooms and making sure they are breathing. I am supposed to sign off on the 15 minute check sheets at mid-shift and check it again at the end of the shift".

B3) Open record review of Patient #19 revealed a 12 year-old female, admitted 07/11/2012 to the latency unit. Review of the 15 minute observation documentation record revealed no RN signature on 07/22/2012 from 1600 until 0000.

Interview on 07/31/2012 at 1330 with administrative management staff revealed the RN should sign all 15 minute observation documentation records at mid-shift to attest their oversight of the mental health technicians completing the 15 minute observation checks. Interview confirmed no RN signature/verification for Patient #19 on 07/22/2012 from 1600 until 0000.

Telephone Interview on 08/01/2012 at 1600 with RN #5 revealed, "as the RN, I oversee the 15 minute checks. I make sure they (mental health technicians) are checking on patients by going into their rooms and making sure they are breathing. I am supposed to sign off on the 15 minute check sheets at mid-shift and check it again at the end of the shift".

C) Closed medical record review of Patient #6 revealed a 16 year-old male admitted 02/27/2012 with suicidal and homicidal ideations, depressive disorder and post traumatic stress disorder. Record review revealed the patient was discharged to another facility on 03/23/2012. Review of the record revealed a physician's order dated 03/07/2012 at 0912 for "1. Consult Dr. (name) regarding safety of discharge and medication recommendations. 2. Consult Dr. (name) Psychiatry Safety Evaluation - Previous testing related delusional issues, please consult." Further review of the record revealed ongoing notes related to discharge planning needs and placement of the patient post discharge. Review of the record revealed no evidence the two requested consults were completed. Review of the physician's orders revealed a 24 hour chart check was documented on 03/07/2012 at 0530 with the next 24 hour chart check done at 03/09/2012 at 0129. Record review revealed no 24 hour chart check completed on 03/08/2012. Review of the record revealed no evidence the physician's order for consults was completed.

Interview on 08/02/2012 at 1420 with administrative management staff revealed nursing staff failed to transcribe the order and the consults were not completed. Interview revealed the nursing staff on night shift were expected to do a 24 hour chart review of physician's orders to verify accuracy of completion. Interview revealed the 24 hour chart check was not completed on 03/08/2012 and the order was missed. Interview revealed there was no policy or procedure for the 24 hour chart checks, but it was a known expectation of the night nursing staff. Interview confirmed nursing staff failed to carry out the physician's order.

Based on policy review, medical record review and interview, nursing staff failed to administer medication as ordered and/or per standards of practice for 3 of 9 records reviewed (#7, #12 and #10).

The findings include:

Review of the "Medication Administration" policy (last reviewed November 2011) revealed "Medication preparation, administration and documentation are carried out in a consistent and safe manner by all licensed staff at (name of hospital). ... Procedure ...3. The nurse transcribes the order on the medication administration record. ...6. When there is a doubt about an order, the physician is contacted. ...11. The patient's name and date of birth are the (name of hospital) two patient identifiers. As a third safety measure, if one of the above is not available the patient's photo or a second nurse verification of ID may be used. ...34. All medications are documented on the Medication Administration Record immediately after they are given, never before they are given. ...36. If a medication is held for tests or therapeutic reasons, the following procedure is followed: ...c. Document on the progress note and on the MAR (Medication Administration Record) the reason for holding the medication and notification of the physician. ...f. When a patient refuses any medication, the nurse will initial and circle their initials on the MAR for that date and time medication refused. Nurse will also document in the nursing notes and on the back of the MAR the date and time medication refused and any given for refusal. Patient should be encouraged to take the medications ordered and the MD should be made aware of patient medication refusal. Patient refusal of medications should be communicated in hand-off communication with on-coming staff as well."

1. Closed medical record review of Patient #7 revealed a 54 year-old male admitted 01/04/2012 with depression and psychosis. Record review revealed the patient was discharged on 01/09/2012. Review of the record revealed a "Medication Reconciliation/MD Order Form" dated 01/04/2012 at 2300 that included a physician's order for Hyzaar 50/12.5 1 tablet every day (medication for blood pressure). Further review of physician's orders revealed an order written on 01/07/2012 at 1230 to discontinue the Hyzaar per TI (therapeutic interchange - substitute a different medication on the hospital's formulary and start Cozaar 50 milligrams (mg) and HCTZ (Hydrochlorothiazide) 12.5 mg daily (therapeutic interchange substitute medication). Review of the MAR revealed Hyzaar 50/12.5 1 tablet to be administered at 1000 daily. Review revealed no documentation the medication was administered on 01/05/2012 and 01/06/2012. Review of the MAR revealed the Hyzaar was discontinued on 01/07/2012 and Cozaar 50 mg and HCTZ 12.5 mg daily at 1000 was administered beginning on 01/07/2012. Review of the record revealed no documentation that the patient refused the medication. Review revealed no documentation why the medication was not administered as ordered on 01/05/2012 and 01/06/2012. Review of the record revealed no evidence the physician was notified that the patient was not administered the ordered medication on 01/05/2012 and 01/06/2012.

Interview on 08/01/2012 at 1400 with RN #7 revealed she was the patient's primary nurse on 01/05/2012 and 01/06/2012. Interview revealed the nurse did not remember the patient. The nurse reviewed Patient #7's medical record and was unable to explain why the ordered medication was not administered on 01/05/2012 and 01/06/2012. Interview confirmed there was no documentation of a reason why the medication was not given and no evidence the physician was notified. The nurse stated "I should have documented the medication was not available if that was the case, or that the patient refused. I didn't document, apparently I didn't give it to him. I don't know why."

Interview with a pharmacist on 08/01/2012 at 1520 revealed the order for the Hyzaar written on 01/04/2012 at 2300 was not faxed to the pharmacy until 01/06/2012 at 1328. Interview revealed Hyzaar is not a medication on the hospital's formulary and a substitute medication order was written on 01/07/2012. The pharmacist revealed she was not aware the patient had not received his medication on 01/05/2012 and 01/06/2012 as ordered. Interview revealed nursing staff are required to perform a 24 hour chart check every night that includes a review of physician's orders to verify accuracy with the MAR. Interview revealed no documentation that the 24 hour chart checks were completed on 01/05/2012 and 01/06/2012. The pharmacist stated the medication error should have been caught if the 24 hour checks were done. The pharmacist confirmed the Hyzaar was not administered as ordered.


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2. Review of hospital policy, "Patient Identification/Identifiers", effective 02/2010, revealed, POLICY "It is the policy of (Name of Hospital) that two (2) patient identifiers will be used prior to the administration of any medication... . The two patient identifiers are patient's name and birth date as entered on the patient's wrist band. Patients are involved in the identification process by asking them to state their name. PURPOSE To promote patient safety and the reduction of health care errors. To ensure the accuracy of the patient identification when providing care or services. PROCEDURE 1. No medication or procedures shall be administered or conducted without the staff having used the two patient identifiers to confirm the patient's identity. 2. The two patient identifiers used at (Name of Hospital) are the patient's birth date and the patient's name. Both identifiers will be printed on the patient wristband. 3. The following steps are to be implemented as part of the patient identification process: a. The patient will be asked to state his or her name. Staff will verify the patient's name by looking at the wristband and comparing the verbal and written information against the MAR (medication administration record)... . b. In addition to asking the patient his/her name, staff will compare the birth date written on the wristband against the MAR... . 4. The comparison of patient specific information will be completed at the location where the procedure or intervention will be performed and/or completed immediately prior to the procedure. 5. In the event that the patient refuses to wear a wristband, staff may use the patient photograph and a second staff member who knows the patient in order to confirm the patient's identity.

Observation on 08/01/2012 at 1000 of medication administration on 1 West revealed RN #6 as the medication nurse. Observation revealed Patient #12, a 55 year-old male, approached the window of the medication room. Observation revealed Patient #12 did not have a Patient ID band on his arm. Observation revealed RN #6 asked to see Patient #12's identification armband and the patient replied, "They never gave me another one when the first one fell off. I've been asking for one for over a week so I just gave up". Observation revealed RN #6 administered the following medications to Patient #12 without checking a photograph and having a second staff member confirm the patient's identity: Nicotine 21 mg (milligrams) patch, Librium 25 mg capsule, Thiamine 100 mg tablet, Neurontin 800 mg tablet and Enalapril 5 mg tablet.

Interview on 08/01/2012 at 1015 with RN #6 revealed, "the armbands come from the RESPOND desk. I can't make ID bands on the unit. I know the patient so I didn't need to verify with another staff member". Interview confirmed the hospital's policy for patient identification when administering medications was not followed.

3. Observation on 08/01/2012 at 1000 of medication administration on 1 West revealed RN #6 as the medication nurse. Observation revealed Patient #14, a 41 year-old male, approached the window of the medication room. Observation revealed RN #6 asked Patient #14 if he was allergic to any medication. He responded 'yes, Penicillin'. Observation of Patient #14's identification band revealed, "Allergies Unknown". Observation revealed Patient #14 did not have a red allergy bracelet on his arm.

Interview on 08/01/2012 at 1020 with RN #6 revealed, "I think he's supposed to have a red allergy bracelet on. I'll have to get him one".

Interview on 08/01/2012 at 1035 with RN #7, a nurse on the 2 North A unit, revealed, "patients with allergies should have a red bracelet on. ID (identification) bands never have allergies on it".

Interview on 08/02/2012 at 1430 with RN #6 revealed, "I was wrong yesterday. The red wristbands are for falls precautions, not allergies. Allergies are just written on the MAR".

Interview on 08/02/2012 at 1445 with administrative staff revealed, "we don't have a policy for the way to identify allergies on armbands. Our ID bands need to be changed and delete the field for allergies. Our process needs to be changed for identifying allergies".