HospitalInspections.org

Based upon observation, record review and interview, the governing body failed to:



A.) provide safety measures to keep patients safe from injuries due to falls in 1(#A) of 5(#A-E) patient charts reviewed.

Refer to Tag A0144


B.) provide ongoing assessment of patient medical conditions throughout the hospitalization for 1(#A) of 5 (#A-#E) patients reviewed. Nursing failed to provide documented assessment, interventions, patient education, and place a patient in isolation in a timely manner to provide safety to staff and patients in 1 of 5 charts reviewed.

Refer to Tag A0395

Based upon observation, record review and interview, the facility failed to:

A.) provide safety measures to keep patient safe from injuries due to falls in 1(#A) of 5(#A-E) patient charts reviewed.


Refer to Tag A0144

Based on chart reviews, interview, and policy and procedure review, the facility failed to follow its own policy and procedures to ensure the patients were safe from falls. The facility failed to have working bed alarms in on all the patient beds and staff failed to document at appropriate times for 11 ( #7, 11, 14, 15, 16, 17, 20, 21, 22, 23, and 25) out of 11 patients reviewed.

1.) Review of patient #11's chart revealed an admission on 5/13/2015, at 5:50PM, with a diagnosis of Neurocognitive Disorder with behavioral disturbances, Aggression. Patient #11's chart revealed, he was escorted to the facility on a Peace Officers Warrant (OPC) from The County Sheriff's Department.

Review of the MHT observation check sheet on 5/18/15, at 1:15AM, revealed, patient #11 was allowed to lay in a bed in his room to rest from 1:15AM till 3:30AM, then again from 5:15AM-6:00AM. Patient #11 was documented to be in chair in dining room or dayroom from 5/13/15 (date of admission) until discharge on 5/21/15 except for these 3 hours documented on 5/18/15.

Review of patient #11's chart revealed from 5/13/15 through 5/16/15, revealed, the patient had received a chemical restraint of Haldol 10mg, Ativan 2mg, and Benadryl 50mg IM, a total of 6 times in a span of 3 days. Review of the daily nurses notes for 5/19/2015, at 8:00AM, stated, "Pt is sedated. Will open his mouth to eat and take meds but will not open his eyes to look at nurse or speak. Re-evaluated med regime per Dr. Johnson. Pt remains lethargic and non- communicative. "RN documented the patients thought content was unable to be assessed. Neurological status was "sedated" and the patients breath sounds were diminished.

Review of the MHT observation check sheet on 5/18/15, at 1:15AM, revealed patient #11 was allowed to lay in a bed in his room to rest from 1:15AM till 3:30AM and again from 5:15AM-6:00AM. Patient #11 was documented to be in a Geri- chair in dining room or dayroom at all other times during his stay at the facility. Review of the nurses notes from 5/16-5/21 revealed patient #11 had a bed alarm on his bed but not in the Geri-chair.

An interview was conducted on 9/23/15, with Staff #13. Staff #13 reported, when a patient is medicated for behavior issues the RN should stay with the patient. Staff #13 stated, "Since there is only one RN and the LVN is passing medications I have to put the patient in the recliner or chair and sit them by the desk so I can monitor everybody else." Staff #13 confirmed the patients have to stay the entire shift, in the dayroom, and not allowed to lie down in the bedroom due to staffing shortages. Staff #13 reported that administration did not encourage 1:1's (1 staff member to 1 patient within arm's length.)

Review of the policy and procedure "Fall Assessment/Re-Assessment and Precautions" stated,

"Policy:
All patients will be assessed and identified for the potential of being at risk for falls upon admission and every 7 days and/or immediately after a fall if identified as moderate or high risk. In the event of a fall occurrence, patients will be re-assessed every day, moved to a higher fall risk, and secondary fall prevention interventions will be implemented. The RN utilizing the Fall Risk criteria score sheet, will assess/re-assess and determine the risk of all patients with regard to falls and implement fall precautions
if so indicated."

The Admitting RN:
Assessment:

At the time of patient's admission, evaluates patient's ambulatory status and completes Fall Risk criteria. If a score of 6 or greater is obtained, initiates fall precautions.

Patients will be scored as follows: 0-6: Low Risk (Reassess as needed)
7-16: Moderate Risk (Initiate Fall Precautions) Greater than 17: High Risk (Add Secondary Interventions) If fall precautions are identified, High Risk for Falls Treatment Plan is initiated by RN.


Fall precautions - Interventions for High Risk:

All of Moderate Risk Interventions Bed alarm highly recommended for night time use (nursing decision is based on patient variables) Non- skid footwear"





Surveyor: Tucker, Susan A.

Review of the facility's "Performance Improvement Program - Quality Monitoring...RISK MANAGEMENT INCIDENT REPORT" monthly reports revealed the following information:


For the month of May 2015, there were 13 incidents reported. 12 of the incidents were patient falls and 1 was an incident that involved an employee and a patient in which the patient received a hand injury. Of the 13 incidents reported, 5 of them occurred in the patient's room or bathroom.


For the month of June 2015, there were 7 incidents reported. 4 of the incidents were patient falls, 1 was a violent episode by a patient that resulted in the patient slapping an employee in the face, and 2 were patient decline in physical condition warranting transfer to the Emergency Room for evaluation. Of the 7 incidents reported, 5 of them occurred in the patient's room or bathroom.


For the month of July 2015, there were 8 incidents reported. 5 of the incidents were patient falls, 2 were medication errors, and 1 was a patient suicide attempt. Of the 8 incidents reported, 2 of them occurred in the patient's room or bathroom.


For the month of August 2015, there were 14 incidents reported. 5 of the incidents were patient falls, 2 were listed as "employee incident" with no further explanation, 1 was listed only as "VIOLENCE", and 8 were listed only as "SECLUSION/RESTRAINT". Of the 14 incidents reported, 6 of them occurred in the patient's room or bathroom.


An interview with staff #5 (the facility's Safety Officer) revealed the following information:
For the month of March 2015, there were 16 fall incidents reported.
For the month of April 2015, there were 7 fall incidents reported.


On 9/23/2015, at approximately 3:30 p.m., a tour of the patient rooms was conducted by the surveyors and administrative staff. Surveyors discovered that the facility had 13 patients (patient #7, #14 through #25) at the time of the tour. Out of the 13 patients in the facility, 10 patients (patient #7, #14, #15, #16, #17, #20, #21, #22, #23, and #25) were documented by the nursing staff as having a bed alarm installed on their bed. The surveyors toured each patient room and tested each bed alarm found. The bed alarms being used were mounted on the wall approximately 2 feet above the head of the patient beds. The system had a sensor that was operated by battery power and when turned on was supposed to alarm if any motion was detected. All rooms assigned to patients with documented bed alarms did not have functioning bed alarms. 6 patient's beds (patient #7, #14, #16, #17, #20, #22) bed alarms did not alarm at the appropriate signal (motion) when tested. 4 patient's beds (patient #15, #21, #23 and #25) with documented bed alarms did not have an alarm installed in their rooms.


A review of the facility's policy, "NSG-30 Fall Alarm" revealed the following information:

"Nursing Surveillance & Response:.....

The alarm will be checked to verify proper mechanical functioning at least every shift.....

Purpose:
The fall alarm is an electronic monitoring system which may be used as part of the fall prevention program in situations where continuous surveillance is not necessary. The system consists of a control unit and a sensor pad. As weight is lifted off the sensor or movement occurs the alarm is activated."


An interview with staff #1 on 9/23/2015, at approximately 4:00 p.m., confirmed the findings that the facility's bed alarms were not working properly. Staff #1 stated, "I hate those bed alarms anyway. I have ordered 5 new ones but, haven't received them yet. I have to order a small amount each month because they are expensive."



A review of the facility's policy "TX-SPEC-05: Level of Observations/Monitoring" revealed the following information:

"Observation Levels:

Every 15 minutes - the staff member should visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities....

Close Observation Form:
The staff member utilizes the close observation form to document the location of the patient....

Procedure:
Every 15 Minute Observation:...
Assigned Nursing Staff (MHT):
· Circles/writes the type of specialty observation on the form (fall, suicide, etc.)....
· Physically walks to find each patient on q (every) 15 minute observation....
· Documents the location on the close observation form. Documents the activity when indicated (water offered, etc.)
· Initials the form every 15 minutes."


On 9/22/2015, at 2:30 p.m., a review of the facility's "Observation Notebook" containing a "Close Observation Check Sheet" for each patient with orders for every 15 minute observation revealed the following information:


There were 4 patient observation sheets (patient #15, #18, #22 and #26) dated 9/22/15 that had not been documented on since 9:15 a.m.


An interview conducted with staff #8 (MHT) confirmed that staff is not documenting the visual observations of each patient every 15 minutes. Staff #8 was asked how she could remember where and what each patient was doing 5 hours later when she documents on the observation sheets, she stated, "I just kinda know where they all have been most of the time." When staff #8 was asked if she made written notes to help her remember all the different patient's whereabouts, she stated, "No I don't write it down. I just kinda know what they were doing."

Based on chart reviews and interviews during revisit on 11/11/15, nursing failed to provide safety measures to keep patient safe from injuries due to falls in 1(#A) of 5(#A-E) patient charts reviewed.


Review of patient A's chart revealed she was placed on fall precautions upon admission on 10/21/15. Review of the multi-disciplinary note on 11/8/2015 at 10:45PM revealed the patient was found sitting up on mat beside pt. bed. Patient A was found by the MHT who was assigned to the patient. Nurses notes revealed "pt. reports she was sitting up on the side of the bed when she slipped off side of bed onto the floor/mat and landed on backside. Pt denies and c/o pain or injuries". Patient A was assessed and vital signs were taken. Nurse practitioner was notified. There was no documentation that the patient was put on a bed alarm or a 1:1 to prevent any further falls. There was no further nursing documentation found on this patient until 11/9/2015 at 4:05AM a total of five hours.

Review of the multi-disciplinary note on 11/9/2015 at 4:05AM revealed another fall for patient A. The note stated, "Patient sat up in bedside stating," I want to go to the hospital " , then propelled herself forward off the bed onto the floor with part of body on mat with facial part on floor. Pt had large puddle of blood under face upon nurse arrival to bedside. Pt was noted to have puncture to chin and swelling to upper lip along with bruising. Pt c/o pain all over especially facial area. Dr. arrived at patient room at 4:10AM. Received verbal order for pt. to go to the ER to rule out fractures." The patient's son was notified. The patient was taken by ambulance to the hospital.

There was no documentation to clarify who witnessed patient #A asking to go to the hospital and "propelling to the floor." The nurse did not enter the room until the patient was on the floor. There was no documentation that the bed alarms went off to alert the staff or why the patient was not put in close observation or on a 1:1 observation after the first fall.











35515

Based upon observation, record review and interview, nursing failed to;


A.) provide ongoing assessment of patient medical conditions throughout the hospitalization for 1(#A) of 5 (#A-#E) patients reviewed. Nursing failed to provide documented assessment, interventions, patient education, and place a patient in isolation in a timely manner to provide safety to staff and patients in 1 of 5 charts reviewed.



Refer to Tag A0395

Based upon record review and interview, Nursing staff failed to provide ongoing assessment of patient's medical condition throughout the hospitalization for 2 (#1, #11) of 6 patients review. Nursing failed to provide assessment and notify physician when a change of condition occurred for 6 (#1, #3, #5, #7, #9, #11) of 6 patients reviewed. Nursing failed to obtain physician's orders for emergency psychoactive medications that were given to 2 (#1, #11) of 6 patients reviewed.

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients causing harm to 2 patients, the likelihood to cause harm, serious injury, impairment and/or subsequent death.


1.) Review of patient #1's chart revealed an admission on 6/15/2015 with a diagnosis of Neurocognitive Disorder (Dementia) with behavioral disturbances. Patient #1 was 87 years old, 5'10", and weighed 130 lbs at admission. Patient #1 had episodes of aggression and had hit another patient at the nursing home. Patient #1 was admitted as a voluntary patient to the facility. Review of the physician history and physical dated 6/17/15, at 6:20AM, stated, "Chief Complaint- Dementia. Mental/Emotional Status; Pleasant Confused."

Review of patient #1's physician orders for 6/15/2015, revealed patient 31 was placed on seizure, assault and fall precautions.

Review of patient #1's daily nursing notes for 6/16/2015, 7AM-7PM revealed patient #1 was mobile in his wheelchair but remained confused and delusional. In the section for precautions the nurse only checked fall precautions. Review of the vital sign record revealed the patients oxygen saturation (O2 sat) was 95 at room air. Review of the chart revealed there was no nursing documentation found for 6/16/15 for the 7PM-7AM shift or for 6/17/15, 7AM-7PM. The next nursing documentation was on 6/17/15, at 7PM-7AM, a lapse of 36 hours.

Review of patient #1's daily nursing notes dated 6/17/2015, 7PM-7AM, revealed patient #1 has had increased confusion and had kicked a Mental Health technician (MHT) on that shift. Patient #1's O2 sat was 94% on room air but lung sounds were clear. There was no further documentation of MD notification of decreasing O2 sat. RN stated, "Remains cooperative and easily re-directed." Nurse only checked falls for safety precautions observed.

Review of patient #1's daily nurse's notes revealed there was no nursing documentation or assessments found for 6/18/2015. No nursing documentation for 36 hours.

Review of the Nutrition assessment completed by the Dietician on 6/19/15, revealed patient #1 had a history of a Cardiovascular Accident (CVA) but had no issues with swallowing. Patient #1 had consumed 75% of his meal and drank a supplement. Dietician's plan stated, Glucerna 1 can twice a day, monitor weight, and monitor for s/s of choking.

Review of patient #1's daily nurse's notes for 6/19/2015, revealed the patient was now on choking precautions. There was no documentation found of physician notification.

Review of patient #1's chart revealed there was no nursing documentation for 24 hours from 6/21/15, at 10:25PM, until 6/22/15, at 10:15PM.

Review of patient #1's daily nurses notes for 6/24/15, revealed there was no found nursing documentation for 6/24/15, 7AM-7PM. Review of the nurses note for 6/24/15, 7PM-7AM revealed the patient was pacing in wheelchair. "Easily redirected."

Review of patient #1's chart revealed a "Physician's Order for Emergency Administration for Psychoactive Medication" dated 6/25/15, at 7:00AM.

The order read," Haldol 5mg IM now, Benadryl 50mg IM now, and Ativan 2mg IM now for severe agitation."

Review of patient #1's chart revealed a "Multi-Disciplinary Note" dated 6/25/2015, at 6:55AM. The RN documented, "Patient was physically and verbally aggressive with one of the techs. Pt stated, "You bitch leave me alone I'm going to piss on the floor." Patient was swinging at staff. Patient #1's daughter was notified of medication administration."

There was no documentation of a comprehensive patient assessment to determine the need for other types of interventions before using a drug or medication as a restraint. There was no documentation found of what interventions were attempted, how the patient responded, or what provoked the behavior.

Review of the daily nurse's notes on 6/25/15, revealed there was no found documentation on patient #1 for the 7AM-7PM shift. There was no further documentation found of any patient assessment until 8:15PM, on 6/25/2015. There was no found documentation if the patient tolerated the medication or effectiveness. RN documented, "Patient asleep at start of shift no behavior."

Review of the physician orders on 6/26/15, at 10:50AM revealed a verbal order, "Benadryl 50 mg IM now EPS."

EPS (extrapyramidal symptoms) are serious side effects associated with the administration of antipsychotic medications. Examples of EPS include rigidity, akathisia (restlessness), and acute dystonic reactions such as tightening of muscles in neck or throat.

Review of patient #1's chart revealed there was no daily nurse's note for 6/26/15, on the 7AM-7PM shift. Review of the 6/26/15, 7PM-7AM daily nurse's note revealed there was no found documentation of EPS symptoms. The RN had documented under Neurological/L.O.C. "Unimpaired."

Review of the physician progress notes for 6/26/15, revealed no reason for the Benadryl IM order. The medication and EPS was not documented in the physician progress note.

Review of the physician orders on 6/27/2015, at 10:20AM, revealed a verbal telephone order to discontinue Zoloft and "start Valium 5mg at 6am and 6pm for anxiety and agitation daily and Trazadone 50mg po QHS for insomnia."

Review of the daily nurse's notes for 6/27/15, at 7AM-7PM shift, revealed patient #1 was agitated and anxious. The RN documented, "Patient is confused. Pt was sitting at nurse's desk and reached out to hit a tech that was standing beside him. Pt was redirected to drink his coffee. Pt complied. I will continue to redirect as needed." There was no documentation found of new medication ordered, administered, or effectiveness of new psychotropic medication.

Review of the daily nurse's notes on 6/28/15, at 8:00AM, revealed the patient is now hallucinating and picking at the floor. There is no documentation that the physician was contacted about the change in condition. Review of the physician progress note on 6/28/15 does not mention the hallucinations or EPS.

Review of the physician orders on 7/2/2015 at 8:30AM revealed patient #1 had new orders to discontinue the Invega and to start on Risperdal 0.5mg twice a day. Increase Valium to 10 mg twice a day.

Review of Risperdal use, dosage, and side effects revealed the following:
" WARNING
INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA RELATED PSYCHOSIS

Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. RISPERDAL® (risperidone) is not approved for the treatment of patients with dementia-related psychosis. [See WARNINGS AND PRECAUTIONS] "

Review of the daily nurse's notes for 7/2/2015, at 8:15AM, stated, "Easily agitated. Refuses asst from staff. Irritable. Isolates to self. Withdrawn. Redirection and verbal support provided. Pt not easily receptive but will calm himself if given quiet time. Will continue to follow closely and assist his care as needed." There was no nursing documentation concerning the medication changes and evaluation of changes for 7/2/2015.

Review of a Physician Progress Note dated 7/2/2015, at 1:10PM, revealed the Nurse Practitioner (NP) saw patient#1. The NP stated, "Pt seen: Health status exam: Up via w/c, very quiet, staff report pt barely able to eat lunch, and returning him to bed. Barely responds to inquiry ...states he is tired and wants to go to bed ...discussed holding meds Staff report pt. is usually verbally aggressive and easily agitated. Vital signs Temperature (T) 96.7, Pulse (P)78, Blood Pressure (BP) 102/58, Respirations (R) 16, and Oxygen Saturation (SAT): 94 %" ( did not indicate on room air or oxygen.) There was no further documentation of who was to hold medications or if medications were held.

Review of patient #1's medication record for 7/2/15, revealed the patients Lopressor (antihypertensive) 50 mgs was held at 6:00AM due to a decrease in blood pressure 102/58 and again at 6:00PM B/P was 112/70. There was no documentation in the nurse's notes that MD was notified. Patient #1 was administered Trazadone 50mg and Valium 10mg at 6:00PM. No further evaluation of blood pressure.

Review of the physician orders for Friday 7/3/15 at 10:30AM revealed an order to increase the Risperdal to 1 mg twice a day.

Review of the nurse's multi-disciplinary notes on 7/3/15 at 11:15AM revealed a note documented by the LVN, "Patient sitting in w/c at dining room table, sleeping, very difficult to arouse. V/S 122/75, 61, T96, R-16, 98% on room air. Sternal rub done by charge nurse. Patient moaned and tried to get nurse to stop. Patient moved to recliner to rest. Patient woke during transfer. V/S WNL nurse practitioner notified and Psychiatrist to be notified."

There was no documentation of decreased LOC, sternal rub, or close observation documented by the RN. Review of the RN assessment for 7/3/2015, "all day asleep." No other information was documented on holding the patients medications, patient assessments, psychiatrist notification, or if patient required closer observation.

Review of the multi-disciplinary note dated 7/4/15, at 5:30PM, revealed patient #1 was sent to the ER for Bradycardia and unresponsive to sternal rub. The RN also wrote a verbal physicians order, given by the NP, to transfer the patient to the ER on 7/4/2015, at 5:30PM. However, the patient ER note states he was sent on 7/3/15 at 5:42PM. The RN had written the wrong date on the order and the nurse's note.

Review of the multi-disciplinary note dated 7/4/15, at 1:30AM, revealed patient #1 returned from the ER. RN documented patients daughter notified. Will continue to monitor closely. There was no other nursing assessment documented. There were no vital signs or a head to toe assessment to document any changes.

There was no daily nurse note found for the evening shift of 7/3/2015. There was no patient assessment documented from 7/3/2015, at 2:00PM, until 7/4/2015, at 12:00PM, a 22 hour span. There was only documentation of the patient leaving the facility and returning from the ER.

Review of the ER notes on 7/3/2015-7/4/2015 by the hospital ER physician stated,

"Additional Notes: Resume nursing home medications and orders. However, it is probably not the best idea to give Valium, Risperdal. Cogentin, Dilantin, and Depakote all at 18:00 (6:00PM), and then follow it up with Trazodone at 21:00 (9:00PM). Any one of those medications can be sedating, so it is not surprising that all of them given together would cause him to be unresponsive, Therefore, please have his physician reconsider his nighttime medications to avoid having this happen again."

Review of the physician progress note on 7/4/2015, at 11:40AM, revealed the NP saw the patient again and stated, "Up and out to meal...doing well ...staff report sent out to ER last PM and returned w/recommendations for med chg ...this to be referred ...Responds well to inquiry ...denies C/O ...staff report no px management today either behavioral or medical. V/S T97.6, P: 62, B/P: 143/59 R: 17 Sat: 97%."

Review of the nurse's daily notes dated 7/4/15, at 12:00PM, revealed the RN documented all systems were normal and wrote "sedated" under behavior column. RN documented, "pt slowed medication held/MD notified. Pt stimulated and reports no complaint. Will continue to monitor closely." There was no further nursing documentation.

Review of patient #1's medication record (MAR) on 7/4/15, revealed Lopressor was held at 6:00AM due to B/P 100/67, Valium 10 mgs at 6:00PM, and Trazodone 50mg at 9:00PM. Nurse documented on MAR "pt already sleepy. Hard to wake."

Review of the physician orders for 7/5/15, at 6:00PM, revealed a verbal order to decrease the Valium to 10 mg once daily at 6:00PM, decrease Risperdal to 1mg at 6:00PM. Another verbal order was taken at 8:20PM to administer Benadryl 50mg IM now and every 2 hours for EPS.

Review of patient #1's MAR for 7/5/2015 revealed patient #1 received the following medications:
1. Benadryl 50mg IM at 9:00PM and 11:00PM.
2. Lopressor 50mg by mouth at 6:00AM and 6:00PM
3. Risperdal 1mg by mouth at 6:00AM and at 6:00PM
4. Cogentin 1mg by mouth at 6:00AM and 6:00PM
5. Valium 10mg by mouth at 6:00PM.
6. Trazadone "refused Trazadone tonight." There were no vital signs documented for 7/5/2015.

Review of the nursing assessment for 7AM-7PM shift on 7/5/15 revealed the nurse did not fill out the patient systems assessment. There was no documentation of any EPS symptoms documented for the 7AM-7PM and 7PM-7AM shift. Review of the physician progress notes for 7/5/15 revealed no documentation of EPS symptom to justify Benadryl injections.

Review of daily nurse's notes dated 7/7/15 at 9:00AM revealed the nurse documented under hours of sleep, "slept on and off today. Pt did not sleep during night shift as reported by nurse." Under the Neurological/LOC section the RN documented, " + confusion, tremors, and seizures v/s T-95.5, P-78, R-15, B/P 157/96. Temp f/u -97.2." There was no further documentation found of a seizure, assessment afterwards, if the physician was called, or when this follow up temperature was taken. There was no physician documentation on 7/5/15 of tremors, seizure, or EPS symptoms.

Review of patient #1's physician orders on 7/10/15, at 11:30AM, revealed a verbal order to increase Risperdal to 2mg by mouth twice a day for psychosis. There was no nursing documentation found of increased psychosis, or EPS symptoms in nursing or physician documentation. There was no teaching provided to patient or consent from patient for increase in psychotropic medication. Review of the daily nursing notes revealed there was no notes for the day shift 7AM-7PM on 7/10/15 -7/14/2015.

Review of the multi-disciplinary note for 7/14/15, at 4:00AM, revealed the RN documented, "During medication pass (AM), pts medication was given with pudding. Pts swallowing appeared slowed and insufficient. Pt began allowing medication to drool from mouth. (Note: medication was crushed and combined with pudding for affective pallibility.) " There was no daily nursing note found for this shift. There was no further nursing assessment or evaluation of LOC. Patient #1 had no medications ordered for 4:00AM.

Review of the multi-disciplinary note for 7/14/15, at 4:30PM, revealed , "oral temp 89.9. Pt assessed and rectal temp was 90.1. On taking rectal temp impaction noted. Notified Dr. Todd re findings. Note new orders. Orders implemented. Temp evaluated in the room and blankets applied. To f/u per results."

Review of patient #1's chart revealed patient#1 had three bowel movements from 6/15/15-7/13/15. Review of the chart revealed the only bowel movements were on 6/16, 6/23, and 7/10/15. There was no documentation of nursing assessment of bowel movements or possible impactions.

Review of patient #1's physician orders for 7/14/15, at 4:40PM, revealed a verbal order to check for an impaction and administered a fleets enema if impacted. If patient had no results to administer a Ducolax suppository x1.

Review of patient #1's chart revealed no found daily nurses note on 7/14/15 or systems assessment. There was no documentation found of impaction removal, patient neurological status, vital signs, or if the physician orders were followed.

Review of patient #1's physician orders for 7/14/15, at 7:00PM, revealed a verbal order that stated, "Send to hospital ER for Hypothermia and R/O GI bleeding. (rectal temp =90.1; large black tarry stool s/p enema."

Review of the physician's History and Physical from the receiving acute care hospital stated the patient was admitted for the following;
1. Encephalopathy (Disease, damage, or malfunction of the brain).
2. Dehydration (occurs when your body does not have as much water and fluids as it should).
3. Dementia (is a general term for a decline in mental ability severe enough to interfere with daily life).
4. Dysphagia (difficulty swallowing).

Patient #1 was hypothermic and was admitted into ICU for IV antibiotics and received a PEG tube (Percutaneous endoscopic gastrostomy involves placement of a tube involving a surgical procedure for placing a tube for feeding.) The GI bleed was ruled out. After 8 days in the acute care hospital patient #1 returned to his nursing home."

Review of the policy and procedure "Nursing NSG-02: Documentation" stated,

"Documentation:
Inpatient:
RN/LVN documents on the Daily Nurse's Note a minimum of once per shift or at the time any pertinent event occurs (may utilize integrated progress notes if additional space is needed). "

Review of patient #1's chart revealed the nurse documented only once in a 24 hour period for the following dates;

a.) 6/16/2015- 6/19/15
b.) no daily nursing notes found for 6/18/15
c.) 6/20/15, 6/22/15
d.) 6/24/15- 6/26/15
e.) 7/1/15 and 7/3/15
f.) 7/4/15- 7/13/15
g.) no notes for 7/14/15

Review of the "Vital Signs- Intake and Output" documentation revealed there was no found vital signs, intake of meals, fluids, output of urine and bowels, or weights on 6/26/15, or 7/4/15- 7/9/15.

An interview was conducted with staff #1 and staff #2 concerning nursing documentation. Staff #2 reported she was aware of the poor documentation but was working on "strengthening the documentation process." Staff #1 confirmed the documentation was poor or absent. Staff #1 was asked who was monitoring and auditing the charts and staff #1 reported the nurses documenting were to do audits. Staff #1 and #2 confirmed that was not an effective plan.

2.) Review of patient #11's chart revealed an admission on 5/13/2015, at 5:50PM, with a diagnosis of Neurocognitive Disorder with behavioral disturbances, Aggression. Patient #11's chart revealed he was escorted to the facility on a Peace Officers Warrant (OPC) from Brazos County Sheriff's Department.

Review of patient #11's "Multi-Disciplinary Note" dated 5/13/15, at 5:50PM revealed patient #11 was brought to the facility by ambulance in four point restraints. Restraints were removed upon arrival to facility. Patient #11 was combative and agitated on arrival. Nurse stated, " Order obtained for injection for severe agitation. Note new orders."

Review of the verbal physician orders for 5/13/15, at 6:10PM, stated, "Give Ativan 2mg IM, Haldol 10mg IM, and Benadryl 50mg IM now 1 time dose for severe agitation." Review of the medication administration record (MAR) revealed medication was administered on 5/13/2015, at 6:10PM. There was no documentation found of injection site.

Review of the chart revealed there was no interventions documented before the administration of psychoactive medications 0n 5/13/15, at 6:10PM. There was no "face to face" done by the physician for a chemical restraint. There was no assessment of patient's v/s or physical/mental status, or medication effectiveness after the administration of medication.

Review of the Multi- Disciplinary Note dated 5/13/15, at 9:00PM, stated, "Received in report at shift change, information for new admission, pt. is awake, eyes closed up at nurses station in Geri-chair moving legs and arms, removing lap covering and gown, responds to verbal and physical stimuli, does not answer questions, occasionally swats at air, mumbling words, 1:1 staff supervision. S/P sedation no pain or discomfort noted, agitation continues no combativeness at this time." A Geri chair, short for geriatric chair, is an upholstered recliner on wheels that can be pushed around like a wheel chair. It usually has a removable tray. Review of patient #11's chart revealed there was no order found for use of the Geri-chair from 5/13-5/21/2015.

An interview with staff #1 on 9/22/15, confirmed the Geri chairs are not used that often because they have to obtain a physician's order to use it. A Geri- chair can be used as a restraint.

Review of the policy and procedure "Levels of Observation and Monitoring" stated the following:
One-to-One Observation:
Physician/LIP:
Provides order for one-to-one observation based on assessed risk and individual needs.
The physician/LIP must give the order to discontinue a one-to-one level of observation once it is begun.

Registered Nurse:
1.) Explains procedure to the patient. Provides for the respect of the patient.
2.) Shall implement one-to-one order when received.
3.) May invoke a one-to-one observation with approval of the DON or Administrator based on identified risk of patient pending notification of LIP for an order.
4.) Assesses patient's condition regarding danger to self, others, fall risk, psychological factors, elopement and psychosis which places the patient at risk.
5.) Reports assessment findings to physician/LIP and DON.
6.) Assigns a nursing staff to perform one-to-one and relief staff for all breaks.
7.) Documents the reason for the observation by circling on close observation form, precautions type, suicide, fall, etc. If precautions are for fall risk includes a fall risk sticker on the close observation form.
8.) Documents in the patient's chart and nurse report sheet and kardex the level of observation ordered and implemented.
9.) Assigns member(s) of nursing staff to conduct a thorough search of the patient's room and belongings and remove any object that can be harmful to the patient. Monitors belonging per belongings policy."

Review of patient #11's chart revealed there was no order for a 1:1. Review of the staffing schedule 5/13/2015 revealed no documentation of a staff member assigned as a 1:1. There was no documentation of vital signs before or after medication administration.

Review of the MHT's close observation sheet for 5/13/15, revealed patient #11 was to be monitored and charted on every 15 minutes. The documentation reported patient #11 in the dayroom (nurse's station is in the dayroom) from 6:00PM to 6:15AM on 5/14/2015. The next "every 15 minute observation" starts on the next sheet at 7:30AM on 5/14/15. There was no found documentation for 1 hour and 45 minutes.

Review of patient #11's verbal physician orders dated 5/14/15, at 4:00PM stated, " Give Ativan 2 mg, Haldol 10mg, Benadryl 50mg IM now 1 time dose for severe agitation. A nurses note was found for 5/14/15, 7AM-7PM. The nurse documented on the daily nurse's note at 6:55PM. There was no nursing documentation found for behaviors requiring chemical restraint, interventions performed, condition of the patient, or effectiveness of the medication. There was no documentation of injection site.

Review of the daily nurses notes dated 5/14/15, at 10:35PM, stated, "Pt is confused, is irritable and increase anxiousness with agitation, yells out loud, cursing staff, striking staff, After multiple redirections and attempts to reorient, order received Ativan, Benadryl, Haldol injection to be given."

Review of patient #11's MAR dated 5/14/15, revealed patient #11 received Ativan 2 mg, Haldol 10mg, and Benadryl 50mg IM at 10:35PM.

Review of patient #11's chart revealed there was no order found for the administration of psychoactive medications on 5/14/2015, at 10:35PM. There was no found documentation of a face to face done before or after the medication administration. There was no assessment or vital signs documented after the administration of psychotropic medications. There was no found documentation of injection site.

Review of the MHT's close observation sheet for 5/13/15- 5/14/2015, revealed patient #11 was in the dayroom area or at nurse's station. There was no documentation found that patient #11 was taken to his room to rest in a bed away from stimulation. There was no documentation of patient consuming any fluids or food. There is no documentation of any out-put of urine or bowels for 5/13/15 or 5/14/15.

Review of patient #11's MAR revealed patient #11 received an injection of Ativan 2mg, Haldol 10mg, and Benadryl 50mg IM now dose on 5/15/2015, at 10:30AM. There was no documentation of the injection site. There was no physician's order documented for the IM medications.

Review of patient #11's daily nurse's note revealed the RN did not document until 4:10PM a span of 5 hours and 20 minutes later. RN documented, "increased agitation and aggressive behavior as evidence by pt. hitting and kicking and cursing nursing staff. Redirection and verbal support provided."

A one hour face to face was found dated 5/15/15, at 11:30AM. There was no signature of discipline on who performed the face to face. The document stated, " Pt combative with hospital staff- spitting and hitting MHT's, yelling- attempting to climb over Geri-chair increased aggression/agitation. The following interventions were checked:

1.) Verbal support
2.) Offer food
3.) Offer one to one support
4.) Make environmental changes
5.) Redirection
6.) Offer fluids
7.) Verbal de-escalation
8.) Utilize pharmacotherapies as ordered.

A one hour face to face dated 5/15/15, at 11:30AM, under "patient's response to interventions stated, " decreased aggression, agitation- pt. still attempted to hit at staff but became calmer. Ate and drank ensure soon after decreased anxiousness."

Review of the nursing notes and MHT observation record on 5/15/15, revealed the patient was never taken out of the dining room or Geri-chair. There is no documentation on the "vital sign/intake and out put record" that patient consumed any fluids or food. There was no assessment before the restraint or afterwards documented by the RN.

Review of the daily nurse's notes dated 5/15/15, for the 7PM-7AM shift RN documented, "Aggression/sleeplessness: Pt aggressive and swatted at staff members in dayroom. Minimal sleep noted. Redirect/ reorient behavior.

Review of the Multi-Discipline Note for 5/15/15, at 8:30PM, revealed RN documented, "Psychiatrist contacted for pt. aggression and combativeness towards staff. Ordered medication initiated by nursing staff to calm aggression. Drug IM given in (r) arm."

A verbal physician order dated 5/15/15, at 8:30PM, stated, "Haldol 10mg, Benadryl 50mg, and Ativan 2mg IM now, and Q 4 hours PRN for severe agitation, aggression." Review of the MAR revealed there was no documentation of medication administration for the IM medications or injection site on 5/15/15, at 8:30PM. Drugs used as a chemical restraint may not be ordered as PRN (as needed).

Review of the one hour face to face Evaluation form dated 5/15/15, at 9:35PM, stated, "Severely agitated and swinging and an attempt to hit staff, hollering".

The following interventions were checked;
1.) Verbal support
2.) Encourage appropriate expression
3.) Offer one to one support
4.) Diversional techniques
5.) Redirection
6.) Offer fluids
7.) Verbal de-escalation
8.) Utilize pharmacotherapies as ordered.

Vital signs were documented as B/P -103/70, P- 68, R-18, and O2 Sat: 95%. RR documented, "findings from the evaluation were reviewed with the psychiatrist on 5/15/15, at 9:35PM. There was no documentation found from the RN on 5/15/15, at 8:45PM if food or fluids were offered. The RN documented at 9:00PM, 9:15PM, and 9:30PM "N/A" for snacks or fluids offered.

Review of the MHT's close observation sheet for 5/15/15, from 12:00AM until 12:00PM, revealed patient #11 was in the dayroom area or at nurse's station. There was no documentation that patient #11 was taken to his room to sleep and rest in a bed with no stimulation. There was no documentation that patient was given IM medications in a private area.

Review of patient #11's Multi-Discipline Note for 5/16/15, at 12:25PM RN documented, "Pt began hitting himself in the head and hitting both of his upper thighs w/ his fists, crying, cursing, screaming, hitting at staff. Pt was a danger to himself and others. Pt was administered an injection per Dr.'s "PRN" order. Pt. restraint and seclusion packet done, Administrator, Dr notified, family not notified d/t pt has not consented. V/s taken. 1 hour face to face completed by RN. 12:25PM Pt. still hitting himself at this time pt has one on one feeding him."

Review of patient #11's MAR for 5/16/2015, at 12:25PM revealed there was no documentation of IM medications given or site of injections.

Review of the One hour face to face form dated 5/16/15, at 12:25, revealed there was no second page with the evaluators name or discipline. The first page stated, "Pt hitting himself on his head and both thighs with his fist. Hitting at self, cursing, hollering. "

Review of the Seclusion/Restraint/Emergency Administration of Psychotropic Medications dated 5/16/2015, at 12:20PM, revealed the patient was given "Emergency Administration of a PRN order." Pt was given "redirection and reorientation." The patient's family was not notified of the administration of psychoactive medications due to "Pt has not consented to notifying family." RN documented the patient was on a 1:1 with staff. There was no order noted for the 1:1. There were no documented vital signs due to " pt refused. " No further interventions or assessments were documented.

Review of the Seclusion/Restraint/Emergency Administration of Psychotropic Medications dated 5/16/2015, at 12:20PM ,the section under "Debriefing with Patient/LAR (contact and document) stated, "Date: 5/17/15 at 2:00PM Pt. confused unable to understand." Below that comment a hand written note was found with an asterisk sign. The comment stated, "Family notified during visitation about the chemical restraints and consent rcvd." The hand written note was in different hand writing and had no name of the author, date, or time. There was no documentation of what family member was notified.

Review of Patient #11's "significant others" written complaint stated, "On May 16 patient (#11) & my daughter & his fulltime caregiver from Oct. 2009-March 2015, drove to Lufkin to see patient at the facility & found him angry, scared, & agitated in a Geri-Chair with feet up head down & all of his weight on his bottom. He had no straps or ties on but he was clearly restrained, unable to get out of the Geri-Chair. He complained of discomfort & of his bottom hurting.

He squirmed constantly & was unable to get comfortable. We ask if he could go to his bed & were told that he would not stay there. The staff called him the wrong name & when I talked to the nurse she told me that his name on his chart was: first name and last name were backwards. She explained to me that they had been unable to call me to inform me of his condition because he had not given consent to release his info to me. They said they had attempted to call his brother & he had told them that I was the POA & Responsible Party The nurse in charge showed me patient's chart and made a list of his meds for me without asking for any documentation or ID.

During our visit on 5/16/15, both of us noticed that patient #11's eyes were sunken, he was gaunt, & his skin was extremely dry. We asked the nurse if he was being watched for dehydration & she assured us that he was offered fluids every 2 hours but often was too agitated to drink. While we were there he motioned with his hand cupped & his mouth in a sucking position that he was thirsty & we got water & helped him drink two full glasses (appox. 12 oz.) during our visit. The nurse assured me that if he showed signs of dehydration they would start IV fluids.

On the dates 5/17/15- 5/20/15, I called the facility at least one time usually in the evening, asked for the nurse and inquired about his condition and was told each day he was doing better, much quieter, and one nurse said they just let him sleep in the Geri-chair right by the nurses station so they could keep an eye on him."

Review of the vital signs and intake/output form dated 5/16/2015, revealed the patient had consumed only 25% of breakfast, lunch, and dinner. Patient #11 had consumed 480cc of fluids.

Review of the nurse's notes for 5/17/2015, 7PM-7AM, revealed patient #11 was still agitated and hitting. The daily nursing note is blank for observation of patient thought content. The RN documented, "Pt. does not speak to me." RN documented that patient #11 was on a 1:1 but there was no physician order found for a 1:1. Review of the vital signs/intake and output record for 5/17/2015 revealed patient #11 had consumed a 1000cc of fluids, urinated x2, and consumed 100% of all three meals.

Review of patient #11's chart revealed there was no nursing documentat