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Based on medical record review and policy review, nursing staff did not ensure vital signs were obtained in accordance with facility policy for Patient #3.

Findings include:

Review on 01/21/15 of policy "Vital Signs #NUR-152" last facility revision 03/26/13 revealed vital signs will include blood pressure, pulse, respiratory rate. Behavioral Health Unit: vital signs on admission, every 8 hours times 24 hours and then daily every morning. All vital signs will be documented in the medical record.

Review of vital signs revealed no documentation to indicate that a blood pressure was obtained on 11/14/14 or that a complete set of vital signs was obtained on 11/15/14.

Based on policy review, medical record review, and interview there is a lack of consistency between the medical plan of care and physician medication orders for Patient #1.

Findings include:

Review on 1/21/15 of policy " Medical Reconciliation " last revised 7/2014 revealed on arrival to the Emergency Department (ED) or upon admission, a complete medical history will be obtained and medications will be reconciled. The provider will carefully consider whether to continue or hold each medication. A complete list of medications will be provided to the next provider upon transfer.

Review on 1/21/15 of the History and Physical dated 09/20/14 at 10:06pm revealed Keppra 2000 mg taken by mouth at bed time were reported (reconciled) in the ED as a current medication. The plan indicates Keppra 1 gm twice daily (previous dose was 2000 mg by mouth at bedtime) will continue.

Review of physician orders revealed an order for Keppra 1 gm twice daily was ordered on 9/25/14 following the patient's seizure activity.

Interview on 01/21/15 at 15:15 with Staff #1, Chief Safety Officer revealed Keppra 2000 mg by mouth at bedtime is listed on the History and Physical dated 9/20/14 at 10:06pm as "reported or reconciled "but the medication was never continued until 9/25/14.