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Based on interview and record review the facility failed to monitor for adverse effects and access the patient's perception of efficacy for medications administered for seven (7) out of ten (10) patients. (Patients #1,2,3,4,5,6,7)

Findings included:

Review of Patient #1's medical records reflected he/she was admitted on 4/7/15 with a diagnosis of Bipolar, Hypertension, Insomnia, and Obesity.
Review of Patient #1's Physician's Orders reflected on 4/11/15 8:35 a.m. he/she was administered Clonidine 0.1 milligram (mg) PO (by mouth) x1 now and recheck blood pressure in one hour. Review of Patient#1's medical records did not reflect the recheck of her blood pressure.

Review of Patient #2's medical record reflected he/she was admitted on 9/15/15 with a diagnosis of Bipolar Disorder and was administered Haldol 10 mg, Ativan 2 mg and Benadryl 50 mg intramuscular x 1 now on 9/15/15 at 2:30 p.m. and Haldol 10 mg, Ativan 2 mg and Benadryl 50 mg intramuscular (IM) x 1 on 9/16/15 at 11:50 a.m.
The effectiveness for both injections was not documented in the medical records.

Review of Patient #3's medical records reflected he/she was admitted on 9/20/15 with a diagnosis of Mood Disorder was administered Seroquel 50 mg PO on 9/20/15 at 9:00 p.m.
The effectiveness was not documented in the medical records.

Review of Patient #4's medical records reflected he/she was admitted on 4/13/15 and was administered Ibuprofen (unknown dose) on 4/15/15 and 4/19/15 and administered Vistaril (unknown dose) on 4/19/15 at 4:30 p.m.
The effectiveness was not documented in the medical records.

Review of Patient #5's medical records reflected he/she was admitted on 4/17/15 and was administered Ibuprofen on 4/23/15 at 1:00 p.m., on 4/24/15 at 10:50 p.m., and on 4/23/15 at 10:00p.m. she was administered Trazodone 100 mg PO. The effectiveness was not documented in the medical records.

Review of Patient #6's medical records reflected he/she was admitted on 4/10/15 with a diagnosis of Bipolar Disorder was administered Mylanta Plus 30 milliliters on 4/10/15 at 9:50 p.m., and on 4/17/15 at 9:00 p.m. Flexeril 10 mg and Vistaril 50 mg PO. The effectiveness was not documented in the medical records.

Review of Patient #7's medical records reflected he/she was admitted on 5/15/15 with a diagnosis of Bipolar disorder and was administered Thorazine 100 mg, and Benadryl 50 mg IM x 1 now for agitation. The effectiveness was not documented in the medical records.

During an interview on 9/21/15 at 2:00 p.m. in the conference room, Staff #5, Pharmacist, stated the pharmacist conducts monthly audits and makes recommendations to the Governing Body. She stated the nurses have been instructed to document the PRN or one time medication administration effectiveness in the medical record.

During an interview on 9/22/15 at 11:30 a.m., in the conference room, Staff #3, Director of Nursing, confirmed the missing documentation and stated the facility was in the process of reviewing the current practice for an effective means of documentation.

Review of the facility provided policy, PRN(as needed) MEDICATIONS(dated 6/10/13) reflected:
Orders for PRN medication must be clear and concise to ensure patients are effectively and accurately treated for the desired condition.
3. The nurse who administers the "PRN" medication will document the purpose for which the medication was given and whether the patient's outcome was effective or ineffective in response to the medication.
4. The provider or nurse will document a patient's perception(s) of the PRN medication in the patient's record.

Based on observation, interview and record review the facility failed to collaborate with the housekeeping staff to provide a hospital-wide infection control program when it failed to provide a sanitary hospital environment on the Adult Psychiatric Unit.

Findings included:

Observations during a tour of the Adult Psychiatric Unit on 9/21/15 at 10:00 a.m. revealed multiple corridors with dirty base boards and numerous dark red to brown dried droplets and small smears on the corridor walls and in a large patient TV area. The patient dining room had a small spider web in two of the corners along the baseboard. The large patient TV room had a long 6 inch tear in the wall, revealing the drywall.

During an interview on 9/21/15 at 10:00 a.m., on the Adult Psychiatric unit, Staff # 4, the Environmental Services Director, stated the facility has a cleaning checklist, but the checklist did not include the walls and the baseboards. He stated he was in the process of creating a new checklist. Staff #4 stated he goes around and checks the units regularly.

During the tour of the Psychiatric Unit on 9/21/15 at 10:00 a.m., Staff #2, the Chief Executive Officer, confirmed the findings.

During an interview on 9/21/15 at 11:00 a.m., in the conference room, Staff #1, Director of Risk Management stated she is over the Environmental Department. She stated she already had a meeting set up for the housekeeping staff to discuss their duties. Staff #1 stated she and Staff #4 were going to be reviewing and revising the checklist. Staff #1 stated the facility has adequate staffing but that they needed additional guidance.

Review of the facility provided policy, HOUSEKEEPING, HANDWASHING WALLS (revised June 9, 2003), reflected:
To allow wall surfaces to be cleaned preventing the spread of infectious agents.
PROCEDURE:
a. This will be done on an as needed basis determined by the environmental services manager.