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Based on record review and interview, the registered nurse failed to ensure the supervision and evaluation of care provided to 3 of 5 sampled patients. This was evidenced by failing to ensure all nursing entries entered into the medical record were a complete and/or accurate account of the patient's behavior. Findings were noted in the medical records of Patient #1, Patient #2 and Patient #4. Findings:

Patient # 1:
Review of the History and Physical revealed Patient #1 was a 61 year old female admitted to the facility from a local nursing home on 12/6/11. Her chief complaints were listed as Paranoia, delusional behavior, and aggressive behavior. Her assessment listed diagnosis which included acute psychosis, Schizoaffective Disorder, and possible mental retardation.
Review of the Patient Observation Logs revealed the patient was listed as having the Precaution Status of VC (Visual Contact). Her behaviors, locations and activities were recorded every 15 minutes by a care assistant assigned to the patient each day.
Review of the Medication Administration Record for Patient #3 revealed the following PRN (as needed) medications had been given by the nursing staff:
12/9/11 0710 Haldol (anti-psychotic medication) 5 milligrams (mg) by mouth (p.o.) for increased agitation and hitting self.
12/14/11 1608 Xanax (an anti-anxiety medication) 0.5 milligrams (mg) for anxiety.
12/16/11 1640 Xanax 0.5 mg p.o. now for increased agitation.
12/19/11 1706 Xanax 0.5 mg p.o. for increased agitation.
Review of the Integrated Progress Notes for Patient #1 dated 2/16/11 at 4:40 p.m. revealed in part: Patient noted with increased anxiety and verbalizing, "I'm afraid. I'm afraid." She ran into an exam room as if hiding and wanted to stay in the exam room ...verbalized, "I'm scared of medicines." Xanax 0.5 mg p.o. administered STAT (immediately) ...
Review of the Patient Observation Logs for the corresponding times of the above mentioned medications revealed the patient was assessed as being cooperative by the care assistant staff.
In an interview on 3/21/12 at 11:28 a.m., the Director of Nursing (S2) stated the nursing staff was responsible for ensuring the accuracy of the clinical associates assessments on the Patient Observation Logs. S2 stated she realized there was a discrepancy in the charting between the nurse's charting and the clinical associate's charting.

Patient #2

Review of the medical record revealed that Patient #2 was a 65 year old female admitted to Magnolia Behavioral Healthcare on 03/03/12 at 4:30 p.m. with diagnoses of Bipolar Disorder, Schizophrenia, Combative Behavior, Grossly Psychotic, and Gravely Disabled.

Review of the physician's orders dated 03/09/12 revealed an observation order, "Remain 1 to 1 while awake, 2 to 1 when in bed HS (bedtime).

Review of the Integrated Clinical Progress Notes (documented by the nurse) and the Patient Observation Log (Documented by the Clinical Associate/Mental Health Technician) revealed the following discrepancies:

03/03/12
Nurse documented
2200 (10:00 p.m.) Patient screaming, "They are killing the babies with apple juice." Unable to calm or redirect.
2240 (10:40 p.m.) Patient continuing to yell out, screaming, unable to redirect or calm.
2300 (11:00 p.m.) Haldol 5 mg.(Milligrams) and Benadryl 25 mg. IM given to RUG (Right upper gluteal) as ordered. CA (Clinical Associate) at bedside.

03/03/12
Clinical Associate documented:
2200 (10:00 p.m.) - Sociable (S).
2230, 2245, and 2300 (10:30 p.m., 10:45 p.m., and 11:00 p.m.) Sociable.

03/04/12
Nurse documented:
0150 (1:50 a.m.) ....Patient yelling out loudly...Has been awake and yelling out loudly since 0120 (1:20 a.m.). Unable to be redirected or clamed with 1:1 attention and comforting. Dr. ___ (S3) notified and orders received to give Haldol 5, Benadryl 25 mg and Ativan 2 mg...
0200 (2:00 a.m.)....Yelling out loudly Speech clear but completely disorganized. Flight of ideas present. Affect flat. Anxious-unable to be redirected...
0300 (3:00 a.m.) Continued to scream out loudly. Becomes aggressive at times, clenching onto nurse's wrist.....
0715 (7:15 a.m.) Patient manic, yelling, mumbling incoherently, disruptive on milieu. 1:1....Patient very agitated, anxious....unable to assess blood pressure due to yelling.
2100 (9:00 p.m.) Rambles on and on. Speech disorganized. Anxious and yells out. Escalates with stimulation

03/04/12
Clinical Associate documented:
0130 - 0300 (1:30 a.m.- 3:00 a.m.) Sociable.
0715 (7:15 a.m.) Behavior - left blank.
2100 (9:00 a.m.) Cooperative

03/06/12
Nurse documented:
1300 (1:00 p.m.) ....Patient noted yelling out and screaming this am. Unsuccessful attempt to calm...
2230 (10:30 p.m.) Patient noted to have increase in anxiety and restless, rambling incoherently. Dr. ____ (S3) present at this time - new orders received and noted.

03/06/12
Clinical Associate documented:
1300 (1:00 p.m.) Cooperative.
2230 (10:30 p.m.) Cooperative.

03/10/12
Nurse documented:
2015 (8:15 p.m.) ....Screaming out at times, chanting. Using inappropriate words, restless, agitated at times....Patient cursing at staff....
2300 (11:00 p.m.) Patient received an IM (Intramuscular) injection of Haldol 7.5 mg, Ativan 2 mg, and Benadryl 25 mg in right gluteal for increased agitation. Patient was in bed yell out randomly, also cursing staff...

03/10/12
Clinical Associate documented:
2015 (8:15 p.m.) Cooperative.
2300 (11:00 p.m.) Behavior left blank. Activity - sleeping.

Similar discrepancies were noted on the dates of 03/12/12, 03/13/12, 03/15/12, 03/18/12, 03/19/12, and 03/20/12.

On 03/20/12 at 3:05 p.m. an interview was conducted with S9RN. When asked if the Patient Observation Log documented by the CA was reviewed by the nurse, S9 stated yes. S9 stated the nurse was responsible to review the Patient Observation Log and ensure the prescribed level of observation was provided and documented.

On 03/21/12 at 11:25 a.m., an interview was conducted with the Director of Nursing, S2. After informed of the discrepancies in the nurse and clinical associate documentation for Patient #2, S2 stated the RN was responsible for ensuring the Clinical Associate monitored and documented the patient's behavior on the Patient Observation Log.


Patient #4:

Medical record review revealed Patient #4 was admitted to Magnolia Behavioral Healthcare on 3/09/12. Documentation on the History & Physical (dictation date of 3/10/12) revealed Patient #4 ' s medical history and assessment data included Hypothyroidism, Diabetes Mellitus type 2, Hypertension, Hyperlipidemia, Parkinson ' s disease, Anemia, Combative behavior, and Psychosis.

Documentation on the Integrated Progress Notes revealed a nursing entry (dated 3/13/12 at 11:30 p.m. by S7-Registered Nurse) that documented in part " Completed assessment on patient @ 2100 and found her to be generally cooperative. When asked where she was stated " I don ' t know, I don ' t care about questions anymore. " Proceeded also to roll over a peers toes in the dayroom and she refused to move out of the way. A few minutes later pt was being attended to the bathroom and she refused to use the bathroom in her room. She wanted to go in the meeting room or the mens room. Attempted to redirect and reorient to where bathroom when she became agitated. She stated, " I want to go in that room " pointing to meeting room. Continue to try to reorient when she became inconsolable and hollering at staff. Stated she would defecate all over herself instead. At this point staff attempted to roll her wheelchair to bathroom, as a result she held on to hallway railing and attempted to bite staff hollering " I don ' t want a bath! " Again we explained she did not have to shower, we were only bringing her to the bathroom. She spit at, attempted to bite and cursed at staff loudly causing a disturbance on the entire unit, disturbing the otherwise calm milieu. Staff placed her on toilet, she used the bathroom and continued to kick and be aggressive and verbally abusive toward staff. Dr. on unit ordered Haldol 5mg (with) Ativan 1mg X1 now to calm her to prevent injury to self and others. Continued to flail in bathroom pounding fist on wall and toilet paper roll stating " I ' m going to break my arm! " At this time she proceeded to cause skin tears on right hand and finger and left hand. Unable to aid her due to continued aggression. Several staff sat with her in bathroom to monitor. After about 10 minutes brought back into dayroom to continue with routine. Pt. continued to de-escalate with less frequent outbursts. Proceeded to cover wound on (left) hand and (right) hand and finger with tegaderm. Took her regularly scheduled meds without problem. Took shower without incident " .

Documentation on Medication Administration Record revealed an injection of 5mg of Haldol and 1mg of Ativan was administered to Patient #4 on 3/13/12 at 9:35 p.m. as ordered.

Documentation on the Patient Observation Log for the date of 3/13/12 revealed inconsistencies with the documentation on the Integrated Progress Notes. Documentation on the Patient Observation Log (completed by S17-Clinical Associate) revealed no indication of Patient #4 being disruptive on the unit on 3/13/12 and/or no indication of Patient #4 exhibiting any aggressive or violent behavior on 3/13/12. All entries entered on the Patient Observation Log for the date of 3/13/12 revealed Patient #4 was cooperative on the unit on 3/13/12.

S7 (Registered Nurse) was interviewed on 3/21/12 at 11:05 a.m. S7 reviewed the medical record of Patient #4. S7 indicated that Patient #4 was verbally and physically aggressive on 3/13/12 at approximately 9:30 p.m. S7 reported Patient #4 ' s behavior escalated after being told she could not use the bathroom in the men ' s room. S7 reported Patient #4 was told she would be taken to her room so she could use her bathroom. S7 reported Patient #4 was upset because she did not want staff to push her to her bathroom because she wanted to use a different bathroom. S7 reported Patient #4 started yelling and threatening staff when they would not allow her to go into the other bathroom. S7 reported Patient #4 grabbed the handrail in the hallway and tried to guide her wheelchair with her feet in an effort to push back when staff were attempting to take her to her room so she could use the bathroom in the room she was assigned. S7 reported Patient #4 ' s behavior continued to escalate out of control and she started banging her hands against the toilet paper dispenser once inside her bathroom despite staff members attempts to redirect her. S7 reported Patient #4 was administered an injection of Haldol 5mg and Ativan 1mg for her behavior and indicated the Haldol and Ativan were effective in treating her behavior.

S17 (Clinical Associate) was interviewed on 3/21/12 at 11:45 a.m. S17 reviewed the medical record of Patient #4. S17 indicated that she was the Clinical Associate assigned to complete the Patient Observation Logs on Patient #4 on the p.m. shift on 3/13/12. S17 reviewed the Patient Observation Log for the date of 3/13/12 and the documentation on the Integrated Progress Notes for the date of 3/13/12. S17 indicated the documentation on the Patient Observation Log for the date of 3/13/12 was inaccurate as Patient #4 was not cooperative on the unit during the entire shift on this date. S17 indicated that Patient #4 was disruptive and aggressive on the unit at approximately 9:30 p.m. on 3/13/12.

S2 (Director of Nursing) was interviewed on 3/21/12 at 11:55 a.m. S2 reviewed the Patient Observation Log for the date of 3/13/12 and the documentation on the Integrated Progress Notes for the date of 3/13/12. S2 verified the documentation on the Patient Observation Log for the date of 3/13/12 was inaccurate as Patient #4 was not cooperative on the unit during the entire shift on 3/13/12.

Review of the Hospital Policy number NU.432, revised 10/20/11, and titled Level of Observation - Therapeutic Safety Measures and Special Observations, revealed the following:
It shall be the policy of Magnolia Behavioral Healthcare to adhere to observation precautions as prescribed by the physician and document patient rounds and behavior on a Patient Observation Log each shift.
H. The RN is to assure that the location graphs reflect V.C. (Visual Contact) and 1:1 status with 15 minute checks. Documentation in the progress note should include level of observation and reason.





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Based on record review and interview, the hospital failed to implement a system that ensures all medication orders (except in emergency situations) are reviewed for appropriateness by a pharmacist before the first dose is dispensed. This resulted in there being no pharmacist review for the therapeutic appropriateness of a patient's medication regimen; duplication in the patient's medication regimen; appropriateness of the drug, dose, frequency, route and method of administration; real or potential medication-medication, medication-food, medication-laboratory test and medication-disease interactions; real or potential allergies or sensitivities; variation from organizational criteria for use; and/or other contraindications prior to first dose administration to patients. Findings:

Patient #2: Medical record review revealed Patient #2 was a 65 year old female who was admitted to Magnolia Behavioral Healthcare hospital on 03/03/12. Documentation in the medical record revealed Patient #2's diagnoses included Bipolar Disorder, most recent episode manic with psychotic features, Schizophrenia, Agitation, Hypertension, and Type 2 Diabetes Mellitus. Documentation on the Psychiatric Evaluation Addendum, dated 03/03/12 revealed Patient #2 was, "Grossly Psychotic and Gravely Disabled". Documentation on the medication administration record revealed Patient #4 was receiving 1200mg of Seroquel in a 24 hours time frame.

Review of the PDR (Physician's Desk Reference) of manufacturer's recommendations revealed the dosage range for Seroquel was 200 - 400 mg twice a day with a maximum of 800 mg per day for Bipolar Disorder, Manic.

In an interview on 03/21/12 at 9:45 a.m., the hospital's contracted pharmacist (S4) indicated that he was aware of dosages of Seroquel exceeding 800mg per day for some patients. When asked what dose of Seroquel would prompt him to contact the physician, S4 stated 1200 mg per day would prompt him to contact the physician. S4 was informed that Patient #2 had received Seroquel 600 mg twice a day on several occasions resulting in a dosage of 1200 mg/day and Haldol/Ativan/Benadryl injections. In a telephone interview on 3/21/12 at 11:30 a.m., the contracted pharmacist reported he did not contact the physician to inquire about the 1200mg dosage of Seroquel that was ordered and administered to Patient #2 in a 24 hour period of time after informing the survey team that a daily dose of 1200mg of Seroquel would prompt him to contact the physician.

The Director of Nursing was interviewed on 3/21/12 at 11:25 a.m. When asked about the process for nurses to follow in relation to new medication orders, the Director of Nursing indicated the process includes a review of the new medication orders, transcribing the orders to the medication administration record and faxing the orders to the contracted pharmacy. When asked if all new medication orders are reviewed by a pharmacist prior to the administration of the first dose of the ordered medication, the Director of Nursing indicated not all new medication orders are reviewed by a pharmacist prior to the administration of the first dose.

The hospital approved policies/procedures relating to medication therapy were reviewed. This review revealed no indication that the hospital had implemented a system that ensures all medication orders (except in emergency situations) are reviewed for appropriateness by a pharmacist before the first dose is dispensed. Review of the hospital's process for ordering, reviewing, and administering medications revealed no evidence to indicate that medication orders are consistently reviewed by a pharmacist before the first dose is dispensed.

The hospital's contracted pharmacist (S4) was interviewed on 3/21/12 at 11:30 a.m. S4 reported the normal hours of operation for the pharmacy was Monday through Friday from 8:30 a.m. till 5:30 p.m. and Saturday from 12:00 noon till 5:00 p.m. The S4 indicated that medication orders are reviewed by a pharmacist during these hours. When asked if medications ordered after the normal hours of operation are reviewed for appropriateness by a pharmacist before the first dose is dispensed, S4 indicated that medications ordered after the pharmacies normal hours of operations are not routinely reviewed by a pharmacist before the first dose is dispensed. S4 indicated that the hospital has not implemented a system to ensure a pharmacist review for the therapeutic appropriateness of a patient's medication regimen prior to first dose administration to patients.