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Based upon records review and interview, the Governing Body failed to ensure that nursing staff provided assessment and appropriate intervention for 3 ( #1, #11, #12) of 13 patients who experienced a change of condition.

A. Nursing staff failed to provide assessment and intervention for patient #11 who suffered an unwitnessed fall, developed a change in mental status and a subsequent change in condition.

B. Nursing staff failed to provide ongoing physical assessment of patient #12 who was admitted with substance abuse issues and multiple medical diagnoses, failed to notify the physician of patient's change of condition, and failed to provide continuous Cardiopulmonary Resuscitation (CPR) prior to his death.

C. Nursing staff failed to provide appropriate assessment for complaints of pain and an unwitnessed fall of patient #1

Refer to A 144, A392

Based on documents review and interviews, the facility:

1. Failed to provided assessment and appropriate intervention for 3 ( #1, #11, #12) of 13 patients who experienced a change of condition.

A. Nursing staff failed to provide assessment and intervention for patient #11 who suffered an unwitnessed fall, developed a change in mental status and a subsequent change in condition.

B. Nursing staff failed to provide ongoing physical assessment of patient #12 who was admitted with substance abuse issues and multiple medical diagnoses, failed to notify the physician of patient's change of condition, and failed to provide continuous Cardiopulmonary Resuscitation (CPR) prior to his death.

C. Nursing staff failed to provide appropriate assessment for complaints of pain and an unwitnessed fall of patient #1.

Refer to A 144

2. Failed to follow its own grievance policy and procedure for 1 (patient #1) of 13 (patient #1-13) patient grievances reviewed.

Refer to A 122

It was determined these deficient practices created an Immediate Jeopardy and caused harm in 3 of 13 patients, two of which resulted in deaths. The deficient practices placed all patients at risk of potential harm, serious injury, and subsequent death.

Based on records review and interviews, the facility failed to address the patient's grievance in writing, follow up with the patient concerning the grievance, or maintain the grievance log according to the facilities policy and procedure for 1 (patient #1) of 13 (patient #1-13) reviewed.

Review of the facility's policy and procedure titled, Patient/Family Complaint and Grievance Procedure, revealed the following:

"POLICY: The Patient Advocate will set a specific time to visit with the complainant to obtain pertinent facts and complete the complaint form. The Patient Advocate will log the complaint on the Patient Tracking log in the patient complaint log book, noting name and date received. After reviewing the facts, including complainants proposed resolution; the Patient advocate will contact the appropriate departments/ individuals to resolve the issue.

PROCEDURE:

A. The individual who has a complaint should go to the Nurse Manager/Designee in an attempt to resolve the issue. The Nurse Manager will resolve the issue or confer with the Clinical Director or the patients physician to resolve the issue.

C. If a resolution cannot be reached, or if the patient wants to proceed directly with the patient advocate they may contact the Patient Advocate for assistance by calling Glen Oaks Hospital and asking for the Patient Advocate. If the Patient Advocate is not immediately available the complainant may leave a message in the Patient Advocate's voice mail. The Patient Advocate will contact the complainant within 24 hours.

D. The Patient Advocate will set a specific time to visit with the complainant to obtain pertinent facts and complete the Complaint Form. (ATTACHMENT A)

E. The Patient Advocate will log the complaint on the Patient Tracking Log in the patient complaint logbook, noting name and date received. (ATTACHMENT B)

F. After reviewing the facts, including the complainant's proposed resolution, the Patient Advocate will contact the appropriate departments/ individuals to resolve the issue.

G. If resolution is not found, the complaint will be forwarded to the CEO/Managing Director. The CEO/Managing Director will conduct such investigation of the complaint as may be appropriate. CEO to notify the Risk Manager.

H. The CEO/Managing Director will issue a written decision within 24-hours of receipt of the complaint.

I. Results of resolutions and corrective actions are to be documented and reported to the CEO/ Managing Director and Medical Director. The information gathered through these actions is reviewed, and this process leads to the development and coordination of in-services, policy changes, QI teams, etc. based on trends or patterns or safety issues. A quarterly report of aggregated data will he reviewed with MEC and the Board of Governors.

J. the patient advocate will assure timely response to each complaint through periodic tracking of the complaint reduction process."

A telephone interview was conducted with patient #1 at 1130am on 12/12/12. Patient #1 reported that she was upset over the use of racial slurs by staff #14 in the dayroom with other patients. They were Hispanic slurs and finally the nurse spoke up and said that's enough. Then it stopped. Patient #1 stated, "I made complaints to the Patient Advocate. The advocate is also the receptionist. She said she was sorry and she would address it. I never heard a word about it after that and I asked more than once."

Chart review on 01/03/2013 at 1030am reveals that there was no documentation of a grievance or complaint made by patient #1. Further review of the complaint log revealed no evidence of a complaint entered for patient #1. There were no notes that the manager had been notified of the incident or having addressed it.

Record review 1/03/2013 at 1400 of staff #14's employee file had a memo from staff #1 with the subject, "Verbal Warning for Inappropriate Conversation" dated 08/28/2012. The memo revealed the following: "Staff was repeating a joke she had heard from a Hispanic comedian on a comedy show. Apparently, the patient had overheard Staff #14 and felt it was demeaning and derogatory. Staff was remorseful and had no intention in offending anyone. She was instructed on language and given the policy."

Interview on 01/03/2012, at 1:30pm, staff #12 was questioned about the complaint and if she remembered it. Staff #12 stated, "Yes I do and it was addressed." Staff #12 was questioned about the complaint form. Staff #12 stated, "I did not fill one out. I didn't think I needed to. I took it to the Compliance Officer. I thought it was resolved without writing it up." Staff #12 was questioned on the policy and if she was aware of the Policy and Procedure on Patient/ Family complaint grievances for the facility. Staff #12 reported that she was not specifically trained on this job. Staff #12 stated, "I have received memos about different things in reporting complaints but no formal training."

Staff #12 was questioned on why there were no complaints logged for the first quarter of 2012. Staff #12 stated, " The Corporate person came down and took them with him. He thought they were copies but they were originals. He ended up shredding them." This action was also confirmed with staff #1.

An Interview was conducted with staff #1 on 01/03/2012 at 5:00pm. Staff #1 stated, "I did investigate the patient's complaint and it was addressed. I wrote a verbal warning and placed it in the employees file. Staff #1 stated, "I don't recall speaking with the patient about it."

Based on documents review and interviews, the nusring staff failed to provided assessment and appropriate intervention for 3 ( #1, #11, #12) of 13 patients who experienced a change of condition.

A. Nursing staff failed to provide assessment and intervention for patient #11 who suffered an unwitnessed fall, developed a change in mental status and a subsequent change in condition.

B. Nursing staff failed to provide ongoing physical assessment of patient #12 who was admitted with substance abuse issues and multiple medical diagnoses, failed to notify the physician of patient's change of condition, and failed to provide continuous Cardiopulmonary Resuscitation (CPR) prior to his death.

C. Nursing staff failed to provide appropriate assessment for complaints of pain and an unwitnessed fall of patient #1.

A. On 1/3/2012 at 10:00 AM, Pt #11 medical record (MR) was reviewed and revealed patient was admitted on 11/15/2012 with severe depression. The Psychiatrist dictated in the "Admission Psychiatric Evaluation" that Pt #11 was suicidal with a plan to overdose. She had severe COPD (Chronic Obstructive Pulmonary Disease), Hypertension and Chronic pain of undetermined cause and was unable to walk. She was 5 feet 6 inches, weighed (wt) 108 pounds (lbs), mobile via wheel chair (W/C) and on continuous oxygen (O2) at 4 liter a minute (L/M). She was noted as a high fall risk.

Review of the PRN (as needed ) medication sheet revealed on 11/25/2012, Pt #11 had 4 episodes of diarrhea (9:30 AM,12:50 PM, 3:00 PM and 9:40 PM) and received PRN anti-diarrheal medication after each episode of diarrhea. On 11/27/2012, one episode of diarrhea (8:12 AM) was reported, with PRN anti-diarrheal medication administered. Review of the nurses notes found no reference to the patient having diarrhea or assessment of the patients' complaint of diarrhea. There was no documentation of nursing intervention and the patient's multidisciplinary care plan made no mention of the PRN medication for the patient's complaint of diarrhea.

Further review of the Pt's MR revealed on 11/24/2012, patient began complaining of increased Shortness of Breath (SOB). Review of the physician's orders revealed patient had new orders written on 11/24/12 for Albuterol 1 vial via hand held nebulizer (HHN) every 4 hours x 3, then every 6 hours x 3, then every 6 hours as needed (PRN) for shortness of breath (SOB). Patient had an order written on 11/18/12 for Albuterol Inhaler ii puffs every 6 hours as needed for shortness of breath. A review of the MR revealed that she complained of increased SOB and PRN medication was given on the following days:

11/24/2012 at 6:55 AM PRN Albuterol Inhaler was given.

11/25/2012 at 1025 PM PRN Albuterol Inhaler was given.

11/26/2012 at 8:00 AM, PRN Albuterol Inhaler was given. At 8:50 AM, PRN Albuterol HHN was given.

11/27/2012 at 10:25 PM, PRN Albuterol Inhaler was given.

11/28/2012 at 7:45 AM, PRN Albuterol Inhaler was given. At 2:00 PM, PRN Albuterol HHN was given.

11/29/12 at 10:00 PM, PRN Albuterol Inhaler was given.

11/30/12 at 6:55 AM and 9:30 PM, PRN Albuterol Inhaler was given. At 10:00 AM, PRN Albuterol HHN was given.

12/1/2012 at 7:00 AM, 1:00 PM, 10:00 PM, PRN Albuterol Inhaler was given. At 9:00 AM, PRN Albuterol HHN was given.

12/2/2012 at 7:13 AM and 10:00 PM, PRN Albuterol Inhaler was documented as given. At 11:20 AM, PRN Albuterol HHN was given.

12/4/2012 at 9:00 PM PRN Albuterol Inhaler was given.

12/6/2012 at 10:00 AM, PRN Albuterol inhaler was given. At 11:00 AM, PRN Albuterol HHN was given. There was no documentation in the nurses notes that patient was assessed, vital signs taken, lung sounds auscultated or any other nursing interventions initiated on the numerous times the patient complained of SOB.

Continued review of Pt #11 MR revealed the following: On 12/6/2012 at 11:45 AM, nurse documented "Nursing staff was notified Pt was found in bathroom between wheel chair and toilet. Fall unobserved by staff. Helped pt. onto toilet, (Pt) verbalized no pain or discomfort, or injuries. Pt. then requested to lay in bed, assisted pt. to bed safely and positioned pt. comfortably offered food and drink...." On 12/6/2012 at 12:30 PM, nursing documentation stated "Pt resting in bed, awake alert and oriented. No distress noted at this time. Pt C/O (complained of), it's something that started yesterday, some medicine is making me feel bad".
Further review revealed 30 minutes later on 12/6/2012 at 1:00 PM "xanax 0.5 mg (milli gram) PO (by mouth) scheduled dose at 1300 (military time) held due to pt's sedation."

There was no evidence found in the record that nursing staff assessed the patient following the unwitnessed fall, before getting the patient out of the floor, after assisting her onto the toilet, or after assisting her to bed. There also was no evidence of V/S being assessed. There was no evidence that the physician was notified of the fall. There was no evidence found in the record that the nurse assessed the pt after the pt complained of "feeling bad". There also was no evidence that the pt. was experiencing a changing level of activity until the documentation the dose of Xanax was held "due to sedation".

On 1/3/2013 in the conference room, the DON confirmed that there were no vital signs documented on Pt #11 after her unwitnessed fall, there was no nursing assessment for injuries related to the unwitnessed fall, the pt's complaint of feeling bad or the patient's sedation.

Continued review of Pt #11 MR revealed on 12/6/12, no documentation for 7 hours and 25 minutes and on 12/6/2012 at 8:25 PM, nursing documentation reflected the following: "staff was alerted by Mental Health Tech (MHT) a zip locked baggie had been found on Pt #11 containing 6 yellow colored tablets, identified by staff as prescription Norco 10/325" (10 mg of Codeine and 325 mg of Tylenol). "MD (medical doctor) notified and order received, discontinue all visitor until ok'd by doctor and search room". At 8:35 PM (pt's) "room searched, contraband found including 1 Norco 10/325". There was no evidence found in the record that nursing initiated or completed an assessment of the pt. following the discovery of 7 pills suspected of being Norco. There was no evidence the nursing staff questioned the pt. regarding consumption of any pills prior to finding the 7 Norco in the baggie. That was all that was documented for this event.

Record review of Nursing policy "NS 1.7 Standard For Patient And Their Environment-
3.5. Environment" revealed :
3.5.2.5 Monitoring of visitors and family in order to educate and prevent patient exposure to contraband.
3.6.6 Upon admission and after supervised visits, nursing personnel will check for and remove aerosols, medications, sharps etc.

Review of nursing documentation revealed there was no documentation that patient had received visitors or that a contraband search had been conducted..

On 1/3/2013 in the administrator office review of the facility policy #NS 4.08 titled "Vital Signs" revealed the following:

1. Standard of care:
1.1 Pt will have vital signs taken and assessed at the time of admission to the nursing unit and at least daily throughout the patient's hospital stay.

2. Standard of practice:
2.1 Vital signs will be assessed by an RN
2.2 Vital signs outside "normal" parameters will be checked again and reassessed by an RN.

3. Vital signs consist of Blood Pressure, Pulse, Respiration and Temperature.

4. Vital sign parameters
4.1 The physician (attending or physician on call) will be notified of vital signs that are outside of the following parameters for additional instructions and orders:
4.1.1. Diastolic pressure less than 60 or greater than 90.
4.1.2 Systolic blood pressure less than 90 or greater than 140.
4.1.3 Pulse less than 50 or greater than 100 beats per minute
4.1.4 Respiration less than 8 or greater that 24; and
4.1.5 Temperature greater than 100.5 degrees Fahrenheit

Continued review revealed documentation of V/S on 12/6/2012 at 9:15 PM as follows: B/P (blood pressure) 80/43, P (pulse) 89, R (respiration) 20. (No temperature was taken). O2 saturation at 98%. There was no nursing documentation explaining why V/S were taken at 9:15 or why the temperature was not taken. There was no evidence the physician was notified.

Evidence revealed the nursing staff failed to follow the facility policy for taking , assessing and reassessing vital signs. There was no evidence found in the record that nursing staff notified the physician of the patient's B/P of 80/43. There was also no evidence the V/S were taken again and reassessed by an RN. The pt's temperature was not documented as taken. The RN failed to recognize the gravity of an 80/43 B/P and failed to identify the need for a Registered Nurse to thoroughly assess and evaluate patient #11 change in condition.

Further review of the MR revealed on 12/7/2012 at 3:35 AM, 6 hours later, nursing documentation showed the following; "3:10-Pt noted with nasal cannula out of nose, upon closer examination, Respiration labored with crackles noted. Would respond verbally after asking question multiple times. Unable to obtain O2 saturation or Blood Pressure. Skin cold to touch. Dr notified and 911 called". Pt #11 was transported via Emergency Medical Service (EMS) to the local acute care hospital. Documentation on 12/7/2012 at 8:50am revealed "Pt was admitted to the acute hospital for pneumonia and sepsis".

Review of patient #11's medical record from the acute care hospital revealed a History and Physical dictated on admission on 12/7/12 that the chief complaint upon arrival was "Mental status change...that improved with 2 doses of Narcan (Medication given to reverse over sedation)." Further review revealed admission blood work was positive for opioid (Codeine). The H&P documented "most likely this was secondary to Norco that she probably took in her room by herself and that she was not supposed to have by herself. This conclusion is drawn after review of all data available to me at this time".

Review of the Discharge Summary from the patient's acute care hospital record revealed the following: "Final Diagnosis: Mulltiorgan failure, Sepsis, Disseminated Intravascular Coagulapathy, Vancomycin Resistant Enterococci (VRE) Urinary Tract Infection, Acute Kidney Injury, Hypocalemia, Peripheral Artery Disease and Respiratory Failure. Disposition: deceased 12/12/2012" (5 days after admission).


B. On 1/3/2012 in the conference room, the MR for Pt #12 was reviewed and revealed Pt #12 was admitted on 12/13/2012 with admitting diagnosis of Major Depressive Disorder (MDD), severe and recurrent without psychosis, history of marijuana abuse, rule out opiod abuse/dependence, morbid obesity, obstructive sleep apnea, recent cardiac oblation, non insulin dependent Diabetes Mellitus (DM), Hypertension (HTN), generalized chronic pain (not otherwise specified), post traumatic stress disorder (PTSD).

Further review of the MR for patient #12 revealed that the psychiatrist documented in the admission evaluation on 12/13/2012, "He does have a history of what appears to be sleep apnea, but it is unclear if his sleep study has acutally been done." The psychiatrist again documented on 12/15/2012, his awareness that Pt #12 had obstructive sleep apnea, however, there was no documentation from the psychiatrist that patient required the use of a CPAP (Continuous Positive Airway Pressure) or that the patient's family was contacted to bring Pt #12's CPAP apparatus to the hospital for use until 12/17/2012 (4 days after admission). Review of admission nursing documentation dated 12/13/12 revealed "Sleep apnea - has CPAP - wife can bring." The nursing staff documented on 12/17/2012 at 5:00 PM, "patient states he left a message for his wife to bring CPAP machine". There was no nursing documentation or assessment of sleep apnea or interventions to ensure patient's respiratory status was monitored while hospitalized. The Multidisciplinary Treatment Plan listed Sleep Apnea as a problem and was documented on a pre-printed form titled "Potential Alterations in Respirations." The pre-printed interventions that had been checked as implemented were to monitor vital signs daily and provide medication education. There was no documentation of interventions for the use of CPAP, monitoring respirations while sleeping, or monitoring the number of hours of sleep.

Further review of the medical record revealed nursing documentation on 12/17/12 at 10:10 pm,"Pt. reports to staff that he fell and hurt his (L) knee, no redness noted. 10:15pm - Blood Pressure 97/65, Pulse 96, assisted patient into bed, Dr. (sic) notified of patient fall and no new orders at this time. Will monitor for safety. 11:00pm-Pt. resting quietly in bed, snores resp. will monitor for safety".

Review of continued nursing documentation (3 hours and 45 minutes later), revealed the following:

12/18/2012 at 2:45 AM, "Pt was found by MHT unresponsive. Nurses X 2 to patient room to examine Pt. Pt not breathing, 911(EMS) called, crash cart to Pt room.

12/18/2012 2:55 AM CPR started, EMT (Emergency Medical Technician) here for assistance".

12/18/2012 2:55 AM, "EMT examined Pt and did not recommend continuing CPR" (Cardio Pulmonary Resuscitation).

12/18/2012, 3:45 AM "Judge notified to make determination for pt".

12/18/2012, 4:00 AM "Judge here to make determination for pt".

12/18/2012, 4:10 AM "Funeral Home...called by Judge...".

There was no documentation that nursing staff notified the on-call physician of the patient's status, received orders on how to proceed with treatment, received orders to transfer patient to acute care facility, or received orders to discontinue CPR. The nursing staff had no physician's orders on how to proceed with treatment for Pt #12. Upon the arrival of the EMS the nursing staff had no physician's order to transport the pt to a higher level of care. Once nursing staff began CPR, the nursing staff had no order to discontinue CPR on the patient.

On 1/28/2013 in the administrator office, the DON was questioned regarding the physician awareness and/or participation in resuscitation attempts for pt #12. There was no response. The DON then confirmed the Automatic Electrical Device (AED) had been discharged, however, there was no evidence the AED had been used for CPR on Pt #12, or that an emergency code had been attempted for Pt #12.



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C. A review of the facility's policy and procedure titled, NS 3.14. Risk to Fall, revealed the following:

"Purpose: 2.1 To reduce the number of patient falls by providing a comprehensive assessment of each patients fall potential risk upon admission and throughout the patients hospital stay.

4.2.1 The unit manager, house supervisor, or designated RN will assess the patient during the admission process to determine if the patient is clinically capable of functioning safely in the unit environment.

4.2.1.1 The RN performing the assessment may discuss with the admitting physician whether a consult for assistive devices is needed.

4.2.6. 'Risk to fall' will be identified as a patient problem on the patient's individualized treatment plan and interventions addressed daily in the progress notes."

A chart review of page 2 of the history and physical examination for patient #1 revealed Staff #18 circled, "yes" to weakness and paralysis. There were no comments or documentation for fall risk or assistive devices needed. On 09/21/2012, staff #17 documented, "Patient has complained of right knee pain and her attending was made aware with orders received. She became nauseated after eating red meat and was brought back from the dining room via wheel chair. Patient started saying, 'I might fall down and if I do I think I should get an x-ray or an MRI.' Patient was advised of new orders to see the emergency medical care consultant in the am." Physician orders by staff #15, dated 09/20/2012 at 1745, read "fall precautions use wheel chair for ambulation." Staff #15 documented the physician gave a second verbal order on 09/20/2012 at 2100, reading "Send patient in am to outpatient x-ray for x-ray of right knee, left forearm and wrist for evaluation of numbness." In a nurse's note dated 09/21/2012 at 1330 staff #17 documented, "Patient to outpatient x-ray staff transport. 1515 patient has returned."

Further chart review of nurse's notes, dated 09/22/2012 at 1915, revealed patient #1 had fallen. Staff #16 documented, "Reported she slipped off shower chair and landed on her buttocks and hit right foot on shower stall. Right foot shows some sensitivity to touch, although no bruising or scratches at site. Full range of motion upon manipulation. No other discomfort noted or reported. Ice pack applied and leg elevated. Patient able to tolerate treatment without complaint." Staff #16 had initiated the "healthcare peer review report." However, it was incomplete and physician response was blank. The "Risk to Fall" precautions on the nursing assessment/observation was blank for 09/19/2012- 9/22/2012.

There was no documentation of any further assessment, vital signs, physician notification, or treatment/care plan interventions.

Observation of patient rooms and shower areas on 01/03/2013 revealed there was no call system to alert staff of falls or emergent care. Further observation of bathing /shower areas revealed shower floors with nonskid surfaces and break away curtains

During an interview on 01/03/2013 at 9:30, staff #5 resported the mental health tech (MHT) or nurse makes 15 min rounds to monitor for needs and fall risk patients are placed in rooms close to the nurses' station. If the patient falls or is unable to call for help it may be at least 15 minutes before help arrives. During an interview on 01/03/2012 at 5:00 pm, staff #1 reported, "All the showers have been replaced with skid proof flooring and rubber protected shower chairs."

A telephone interview was conducted with patient #1 at 1130am on 12/12/12. Patient #1 reported that she had a fall while she was in the hospital but was unsure of the date and time. Patient #1 stated, "My knee was bothering me and I had injured it before the fall. I asked to take a shower and they got me a shower chair to use. I got into the shower and sat on the shower chair. Next thing I knew it slipped out from under me because it had no rubber grips on the bottom. The shower even had missing strips in the bottom of the shower to help keep you from falling. When I fell I knew I had hurt my knee and was unable to get up." Patient #1 reported she had to scream for help because there was no emergency call light. She stated, "I just kept hollering out then finally somebody came. Well, several people came in but they never covered me up." Patient #1 reported she was left lying nude on the floor and was very embarrassed and stated they had to get a male employee to come in and help her get up. She stated, "They helped me get into the wheel chair and dress. The nurse got me an ice pack and medication for pain. No one ever took my blood pressure or sent me for an x-ray." Patient #1 reported she was assessed by a nurse, but was not sent for x-rays until two days after the fall had occurred.

Based upon records review and interviews, the facility:

A. Failed to provide assessment and appropriate intervention for 3 ( #1, #11, #12) of 13 patients who experienced a change of condition.

A. Nursing failed to provide assessment and intervention for patient #11 who suffered an unwitnessed fall, developed a change in mental status and a subsequent change in condition.

B. Nursing failed to provide ongoing physical assessment of patient #12 who was admitted with substance abuse issues and multiple medical diagnoses, failed to notify the physician of patient's change of condition, and failed to provide continuous Cardiopulmonary Resuscitation (CPR) prior to his death.

C. Nursing failed to provide appropriate assessment for complaints of pain and an unwitnessed fall of patient #1.
Refer to A 144, A392

B. Failed to insure that staff accurately evaluated dietary needs for 5 (Patient#1, #2, #5, #7, #10) of 16 sampled patient, failed to establish nutritional treament plans for 9 (Patient # 1, #2, #3, #4, #5, #7, #8, #9, #10 ) of 13 sampled patient, failed to insure the nursing staff followed physician orders in administering medication, and failed to recognize adverse effects of medications administered in 2 (Patient #11 and #12) of 13 patients identified.
Refer to A 0395

C. Failed to identify and evaluate patient's needs and failed to establish a nursing care plan, evaluate the intervention attempted on the plan and failed to maintain the care plan as new problems developed and were identified during the patient's hospitalization and treatment for 9 (Patient # 1, #2, #3, #4, #5, #7, #8, #9, #10 ) of 13 patient's identified.
Refer to A 0396

It was determined these deficient practices created an Immediate Jeopardy and caused harm in 3 of 13 patients, 2 of which resulted in deaths. These deficient practices placed all patients at risk of potential harm, serious injury, and subsequent death.






.

Based on documents review and interviews, the nursing staff failed to provide assessment and appropriate intervention for 3 ( #1, #11, #12) of 13 patients who experienced a change of condition.

A. Nursing staff failed to provide assessment and intervention for patient #11 who suffered an unwitnessed fall, developed a change in mental status and a subsequent change in condition.

B. Nursing staff failed to provide ongoing physical assessment of patient #12 who was admitted with substance abuse issues and multiple medical diagnoses, failed to notify the physician of patient's change of condition, and failed to provide continuous Cardiopulmonary Resuscitation (CPR) prior to his death.

C. Nursing staff failed to provide appropriate assessment for complaints of pain and an unwitnessed fall of patient #1.

A. On 1/3/2012 at 10:00 AM, Pt #11's medical record (MR) was reviewed and revealed that patient was admitted on 11/15/2012 with severe depression. The Psychiatrist dictated in the "Admission Psychiatric Evaluation" that Pt #11 was suicidal with a plan to overdose. She had severe COPD (Chronic Obstructive Pulmonary Disease), Hypertension and Chronic pain of undetermined cause and was unable to walk. She was 5 feet 6 inches, weighed (wt) 108 pounds (lbs), mobile via wheel chair (W/C) and on continuous oxygen (O2) at 4 liter a minute (L/M). She was noted as a high fall risk.

Review of the PRN (as needed ) medication sheet revealed on 11/25/2012, Pt #11 had 4 episodes of diarrhea (9:30 AM,12:50 PM, 3:00 PM and 9:40 PM) and received PRN anti-diarrheal medication after each episode of diarrhea. On 11/27/2012, one episode of diarrhea (8:12 AM) was reported, with PRN anti-diarrheal medication administered. Review of the nurses notes found no reference to the patient having diarrhea or assessment of the patients' complaint of diarrhea. There was no documentation of nursing intervention and the patient's multidisciplinary care plan made no mention of the PRN medication for the patient's complaint of diarrhea.

Further review of the Pt's MR revealed on 11/24/2012, patient began complaining of increased Shortness of Breath (SOB). Review of the physician's orders revealed patient had new orders written on 11/24/12 for Albuterol 1 vial via hand held nebulizer (HHN) every 4 hours x 3, then every 6 hours x 3, then every 6 hours as needed (PRN) for shortness of breath (SOB). Patient had an order written on 11/18/12 for Albuterol Inhaler ii puffs every 6 hours as needed for shortness of breath. A review of the MR revealed that she complained of increased SOB and PRN medication was given on the following days:

11/24/2012 at 6:55 AM PRN Albuterol Inhaler was given.

11/25/2012 at 1025 PM PRN Albuterol Inhaler was given.

11/26/2012 at 8:00 AM, PRN Albuterol Inhaler was given. At 8:50 AM, PRN Albuterol HHN was given.

11/27/2012 at 10:25 PM, PRN Albuterol Inhaler was given.

11/28/2012 at 7:45 AM, PRN Albuterol Inhaler was given. At 2:00 PM, PRN Albuterol HHN was given.

11/29/12 at 10:00 PM, PRN Albuterol Inhaler was given.

11/30/12 at 6:55 AM and 9:30 PM, PRN Albuterol Inhaler was given. At 10:00 AM, PRN Albuterol HHN was given.

12/1/2012 at 7:00 AM, 1:00 PM, 10:00 PM, PRN Albuterol Inhaler was given. At 9:00 AM, PRN Albuterol HHN was given.

12/2/2012 at 7:13 AM and 10:00 PM, PRN Albuterol Inhaler was documented as given. At 11:20 AM, PRN Albuterol HHN was given.

12/4/2012 at 9:00 PM PRN Albuterol Inhaler was given.

12/6/2012 at 10:00 AM, PRN Albuterol inhaler was given. At 11:00 AM, PRN Albuterol HHN was given. There was no documentation in the nurses notes that patient was assessed, vital signs taken, lung sounds auscultated or any other nursing interventions initiated on the numerous times the patient complained of SOB.

Continued review of Pt #11 MR revealed the following: On 12/6/2012 at 11:45 AM, nurse documented "Nursing staff was notified Pt was found in bathroom between wheel chair and toilet. Fall unobserved by staff. Helped pt. onto toilet, (Pt) verbalized no pain or discomfort, or injuries. Pt. then requested to lay in bed, assisted pt. to bed safely and positioned pt. comfortably offered food and drink...." On 12/6/2012 at 12:30 PM, nursing documentation stated "Pt resting in bed, awake alert and oriented. No distress noted at this time. Pt C/O (complained of), it's something that started yesterday, some medicine is making me feel bad".
Further review revealed 30 minutes later on 12/6/2012 at 1:00 PM "xanax 0.5 mg (milli gram) PO (by mouth) scheduled dose at 1300 (military time) held due to pt's sedation."

There was no evidence found in the record that nursing assessed the patient following the unwitnessed fall, before getting the patient out of the floor, after assisting her onto the toilet, or after assisting her to bed. There also was no evidence of V/S being assessed. There was no evidence that the physician was notified of the fall. There was no evidence found in the record that the nurse assessed the pt after the pt complained of "feeling bad". There also was no evidence that the pt. was experiencing a changing level of activity until the documentation of the dose of Xanax was held "due to sedation".

On 1/3/2013 in the conference room, the DON confirmed that there were no vital signs documented on Pt #11 after her unwitnessed fall, there was no nursing assessment for injuries related to the unwitnessed fall, the pt's complaint of feeling bad or the patient's sedation.

Continued review of Pt #11 MR revealed on 12/6/12, there were no documentation for 7 hours and 25 minutes and on 12/6/2012 at 8:25 PM, nursing documentation reflected the following: "staff was alerted by Mental Health Tech (MHT) a zip locked baggie had been found on Pt #11 containing 6 yellow colored tablets, identified by staff as prescription Norco 10/325" (10 mg of Codeine and 325 mg of Tylenol)." "MD (medical doctor) notified and order received, discontinue all visitor until ok'd by doctor and search room". At 8:35 PM (pt's) "room searched, contraband found including 1 Norco 10/325". There was no evidence found in the record that nursing initiated or completed an assessment of the pt. following the discovery of 7 pills suspected of being Norco. There was no evidence the nursing staff questioned the pt. regarding consumption of any pills prior to finding the 7 Norco in the baggie. That was all that was documented for this event.

Record review of Nursing policy "NS 1.7 Standard For Patient And Their Environment-
3.5. Environment" revealed :
3.5.2.5 Monitoring of visitors and family in order to educate and prevent patient exposure to contraband.
3.6.6 Upon admission and after supervised visits, nursing personnel will check for and remove aerosols, medications, sharps etc.

Review of nursing documentation revealed there was no documentation that patient had received visitors or that a contraband search had been conducted..

On 1/3/2013 in the administrator office review of the facility policy #NS 4.08 titled "Vital Signs" revealed the following:

1. Standard of care:
1.1 Pt will have vital signs taken and assessed at the time of admission to the nursing unit and at least daily throughout the patient's hospital stay.

2. Standard of practice:
2.1 Vital signs will be assessed by an RN
2.2 Vital signs outside "normal" parameters will be checked again and reassessed by an RN.

3. Vital signs consist of Blood Pressure, Pulse, Respiration and Temperature.

4. Vital sign parameters
4.1 The physician (attending or physician on call) will be notified of vital signs that are outside of the following parameters for additional instructions and orders:
4.1.1. Diastolic pressure less than 60 or greater than 90.
4.1.2 Systolic blood pressure less than 90 or greater than 140.
4.1.3 Pulse less than 50 or greater than 100 beats per minute
4.1.4 Respiration less than 8 or greater that 24; and
4.1.5 Temperature greater than 100.5 degrees Fahrenheit

Continued review revealed documentation of V/S on 12/6/2012 at 9:15 PM as follows: B/P (blood pressure) 80/43, P (pulse) 89, R (respiration) 20. (No temperature was taken). O2 saturation at 98%. There was no nursing documentation explaining why V/S were taken at 9:15 or why the temperature was not taken. There was no evidence the physician was notified.

Evidence revealed that the nursing staff failed, to follow the facility policy for taking, assessing and reassessing vital signs. There was no evidence found in the record that the nursing staff notified the physician of the patient's B/P of 80/43. There was also no evidence that the V/S were taken again and reassessed by an RN. The pt's temperature was not documented as taken. The RN failed to recognize the gravity of an 80/43 B/P and failed to identify the need for a RN to thoroughly assess and evaluate patient #11 change in condition.

Further review of the MR revealed that on 12/7/2012 at 3:35 AM, 6 hours later, nursing documentation showed: "3:10-Pt noted with nasal cannula out of nose, upon closer examination, Respiration labored with crackles noted. Would respond verbally after asking question multiple times. Unable to obtain O2 saturation or Blood Pressure. Skin cold to touch. Dr notified and 911 called". Pt #11 was transported via Emergency Medical Service (EMS) to the local acute care hospital. Documentation on 12/7/2012 at 8:50am revealed "Pt was admitted to the acute hospital for pneumonia and sepsis".

Review of patient #11's medical record from the acute care hospital revealed a History and Physical dictated on admission on 12/7/12 that the chief complaint upon arrival was "Mental status change...that improved with 2 doses of Narcan (Medication given to reverse over sedation)." Further review revealed admission blood work was positive for opiod (Codeine). The H&P documented "most likely this was secondary to Norco that she probably took in her room by herself and that she was not supposed to have by herself. This conclusion is drawn after review of all data available to me at this time."

Review of the Discharge Summary from the patient's acute care hospital record revealed the following: "Final Diagnosis: Multiorgan failure, Sepsis, Disseminated Intravascular Coagulapathy, Vancomycin Resistant Enterococci (VRE) Urinary Tract Infection, Acute Kidney Injury, Hypocalemia, Peripheral Artery Disease and Respiratory Failure. Disposition: deceased 12/12/2012" (5 days after admission)."


B. On 1/3/2012 in the conference room, the MR for Pt #12 was reviewed and revealed that Pt #12 was admitted on 12/13/2012 with admitting diagnosis of Major Depressive Disorder (MDD), severe and recurrent without psychosis, history of marijuana abuse, rule out opiod abuse/dependence, morbid obesity, obstructive sleep apnea, recent cardiac oblation, non insulin dependent Diabetes Mellitus (DM), Hypertension (HTN), generalized chronic pain (not otherwise specified), post traumatic stress disorder (PTSD).

Further review of the MR for patient #12 revealed that the psychiatrist documented in the admission evaluation on 12/13/2012, "He does have a history of what appears to be sleep apnea, but it is unclear if his sleep study has acutally been done." The psychiatrist documented on 12/15/2012, that Pt #12 had obstructive sleep apnea, however there was no documentation from the psychiatrist that patient required the use of a CPAP (Continuous Positive Airway Pressure) or that the patient's family was contacted to bring Pt #12's CPAP apparatus to the hospital for use until 12/17/2012 (4 days after admission). Review of admission nursing documentation dated 12/13/12 revealed "Sleep apnea - has CPAP - wife can bring". The nursing staff documented on 12/17/2012 at 5:00 PM, "patient states he left a message for his wife to bring CPAP machine."There was no nursing documentation or assessment of sleep apnea or interventions to ensure patient's respiratory status was monitored while hospitalized. The Multidisciplinary Treatment Plan listed Sleep Apnea as a problem and was documented on a pre-printed form titled "Potential Alterations in Respirations". The pre-printed interventions that had been checked as implemented were to monitor vital signs daily and provide medication education. There was no documentation of interventions for the use of CPAP, monitoring respirations while sleeping, or monitoring the number of hours of sleep.

Further review of the medical record revealed nursing documentation on 12/17/12 at 10:10 pm,"Pt. reports to staff that he fell and hurt his (L) knee, no redness noted. 10:15pm - Blood Pressure 97/65, Pulse 96, assisted patient into bed, Dr. (sic) notified of patient fall and no new orders at this time. Will monitor for safety. 11:00pm-Pt. resting quietly in bed, snores resp. will monitor for safety".

Review of continued nursing documentation (3 hours and 45 minutes later), revealed the following:

12/18/2012 at 2:45 AM, "Pt was found by MHT unresponsive. Nurses X 2 to patient room to examine Pt. Pt not breathing, 911(EMS) called, crash cart to Pt room.

12/18/2012 2:55 AM CPR started, EMT (Emergency Medical Technician) here for assistance".

12/18/2012 2:55 AM, "EMT examined Pt and did not recommend continuing CPR" (Cardio Pulmonary Resuscitation).

12/18/2012, 3:45 AM "Judge notified to make determination for pt".

12/18/2012, 4:00 AM "Judge here to make determination for pt".

12/18/2012, 4:10 AM "Funeral Home...called by Judge...".

There was no documentation that nursing staff notified the on-call physician of the patient's status, received orders on how to proceed with treatment, received orders to transfer patient to acute care facility, or received orders to discontinue CPR. The nursing staff had no physician's orders on how to proceed with treatment for Pt #12. Upon the arrival of the EMS, the nursing staff had no physician's order to transport the pt to a higher level of care. Once nursing staff began CPR, the nursing staff had no order to discontinue CPR on the patient

On 1/28/2013 in the administrator office, the DON was questioned regarding the physician awareness and/or participation in resuscitation attempts for pt #12. There was no response. The DON then confirmed the Automatic Electrical Device (AED) had been discharged, however, there was no evidence the AED had been used for CPR on Pt #12, or that an emergency code had been attempted for Pt #12.

C. Review of the facilities policy and procedure titled, "NS 3.14. Risk to Fall" Purpose: 2.1 To reduce the number of patient falls by providing a comprehensive assessment of each patients fall potential upon admission and throughout the patients hospital stay. 4.2.1 The unit manager, house supervisor, or designated RN will assess the patient during the admission process to determine if the patient is clinically capable of functioning safely in the unit environment. 4.2.1.1 The RN performing the assessment may discuss with the admitting physician whether a consult for assuasive devices is needed. 4.2.6. ' Risk to fall ' will be identified as a patient problem on the patients individualized treatment plan and interventions addressed daily in the progress notes.

Chart review of Patient #1's History and Physical Examination form - page 2, Staff #18 circled, yes to weakness and paralysis. There was no comments or documentation for fall risk or assistive devices needed. Patient was advised of new orders to see the emergency medical care consultant in the am." Physician orders by staff #15 dated 09/20/2012 at 1745, " fall precautions use wheel chair for ambulation. " Staff #15 gave a second verbal order on 09/20/2012 at 2100, " Send patient in am to outpatient x-ray for x-ray of right knee, left forearm and wrist for evaluation of numbness. " On 09/21/2012, staff #17 documented "Patient has complained of right knee pain and her attending was made aware with orders received. She became nauseated after eating red meat and was brought back from the dining room via wheel chair. Patient started saying, 'I might fall down and if I do I think I should get an x-ray or an MRI.' Nurses notes dated 09/21/2012 at 1330 staff #17 documented, "Patient to outpatient x-ray, staff transport. 1515 patient has returned."

Further chart review Nurses notes 09/22/2012 at 1915 revealed patient #1 had fallen. Staff #16 documented, "Reported she slipped off shower chair and landed on her buttocks and hit right foot on shower stall. Right foot shows some sensitivity to touch, although no bruising or scratches at site. Full range of motion upon manipulation. No other discomfort noted or reported. Ice pack applied and leg elevated. Patient able to tolerate treatment without complaint. "Staff #16 had initiated the "Healthcare Peer Review Report." However, it was incomplete and physician response was blank. The 'Risk to Fall' precautions on the nursing assessment/observation was blank for 09/19/2012- 9/22/2012.

There was no documentation of any further assessment, no vital signs documented, no documentation of physician notification, and no treatment/care plan interventions.

Interview was conducted with staff #5 on 01/03/2013 at 9:30am. Staff #5 reported the Mental Health Technician or nurse makes 15 min rounds to monitor for needs and fall risk patients are placed in rooms close to the nurses station. If the patient falls or is unable to call for help it may be at least 15 minutes before help arrives.A telephone interview was conducted with patient #1 at 1130am on 12/12/12. Patient #1 reported that she had a fall while she was in the hospital but was unsure of the date and time.

A telephone interview was conducted with Patient #1 made the following statement: "My knee was bothering me and I had injured it before the fall. I asked to take a shower and they got me a shower chair to use. I got into the shower and sat on the shower chair. Next thing I knew it slipped out from under me because it had no rubber grips on the bottom. The shower even had missing strips in the bottom of the shower to help keep you from falling. When I fell I knew I had hurt my knee and was unable to get up. I had to scream for help because there was no emergency call light. I just kept hollering out then finally somebody came. Well, several people came in but they never covered me up." Patient #1 reported, she was left nude laying the floor and very embarrassed. They had to get a male employee to come in and help her get up. She stated, "They helped me get into the wheel chair and dress. The nurse got me an ice pack and medication for pain. No one ever took my blood pressure or sent me for an x-ray." Patient #1 reported she was not sent for x-rays for 2 days.

Based on documents review, the facility failed to ensure nursing staff accurately evaluated the dietary needs and establish nutritional treament plans for 5 (Patient#1, #2, #5, #7, #10) of 16 patients.

On 1/3/2013 at 11:00 AM, in the conference room, the nursing Nutritional Risk Assessment screening tool was reviewed and revealed the following:

The Nutritional Risk Assessment tool was used by the nursing department to screen patients and determine if a Registered Dietician (RD) should also evaluate the patient's nutritional status. The tool evaluated the physician prescribed diet and food allergies.

The tool also assessed the following information, scoring the information at a weight of 10 points:
1. Loss or gain of weight without the patient trying,
2 A history of eating disorders in the past two years,
3.A history of intestinal disorders or surgeries,
4.Diagnosis of HIV (human immunodeficiency virus)/AIDS (Acquired Immunodeficiency Syndrome),
5.Under 18 years of age or
6.Multiple gestations,
7.Newly diagnosed with Diabetes (within the past 6 months),
8 Mal-absorption and/or pressure ulcer,
9.Cancer/wasting syndrome,
10. Renal disease.

The tool also required a review of lab, scoring lab with a weight of 10 points. Lab included the following:
1. Glucose,
2. Hemoglobin,
3. Hematocrit,
4. Cholesterol,
5. Triglicyrides,
6. Albumin.

The Nutritional Risk Assessment also assessed the following, scoring them at a weight of 5 points:
1. Nausea/vomiting/diarrhea for greater than three days,
2. Intake less than 50% for greater than 1 week,
3. Liver disease,
4. Cardiovascular disease,
5. Trouble chewing or swallowing.

A patient would be seen by the RD if the total points, calculated by the RN, after screening a patient, using the Nutritional Risk Assessment, was 10 points or more.

On 1/3/2013, in the conference room, the medical record for patient #1 was reviewed and revealed the following: Pt #1 was screened by a Registered Nurse (RN) for need for consult by the Registered Dietician (RD). The RN scored patient #1, at 5, below the required number to indicate a RD consult was needed. The RN failed to identify pt #1's diagnosis of hypertension (HTN) and a cardiac diet as likely cardiovascular disease (score of 5). The RN failed to recognize gastric bypass surgery as an intestinal surgery (score of 10). The RN also failed to recognize the potential for poor nutritional absorption secondary to gastric bypass (score of 10). However, the RN did document patient #1 as having gastric bypass within 2 months of her admission to the inpatient psychiatric unit. .

Review of patient #2's medical record revealed he was screened by the RN and scored at a 5. Patient #2 was on a cardiac diet with no added salt. He had an admission diagnoses of hypertension and high cholesterol (score 5). Patient #2 indicated in his intake he rarely ate a balanced meal. The RN did not recognize "rarely eating a balanced meal" as a potential weight loss and/or poor nutritional absorption (score 5 and/or 10). There was no documentation that the patient was referred for a dietician consult.

On 1/3/2012, in the conference room, the MR for patient #5 was reviewed and revealed the following: Patient #5 was admitted on 8/31/2012. Her primary psychiatric diagnosis was documented in the initial psychiatric evaluation as bipolar with mixed severe psychotic features. Her medical History &Physical listed History of Myocardial Infarct (MI). Recently, patient was admitted for 2 suicide attempts, with acute respiratory failure requiring intubation. A review of her admission labs revealed positive urinary tract infection (UTI).

A review of the High Risk Notification Alert revealed suicide, sexual victimization, self harm, medically compromised with "liver problems and history of MI" (score 5), and chemical dependency withdrawal from cannabis. Patient #5 was documented as 5 feet 3 inches tall and weighing 145 pounds, 18.5 pounds above her Ideal Body Weight (IBW) range (score 10). Review of the Nursing Nutritional Risk Assessment revealed "No" problems.

Patient #7 was admitted 1/1/2013 with psychotic disorder. He had a medical history of gastric esophageal reflux disorder, unspecified colon surgery (score of 10), hypertension (score of 5) and was measured at 72 inches tall and weighed 264 pounds. This is 64 pounds above his IBW range, based on his height (score of 10). Patient #7 was nutritionally screened by the RN with "No" problems. Patient #7 was not seen by a RD.

Patient #8 was admitted on 10/20/2012 with drug and alcohol addiction. He was 72 inches tall and weighed 141.75 pounds. Patient #8 was 22.05 pounds below his Ideal Body Weight (IBW)range based on his height of 72 inches. The RN failed to identify alcohol addiction with poor nutritional absorption (score of 10) and failed to identify this 6 foot tall man whose weight was 141.75 as below his IBW (poor consumption and /or absorption score 5 or 10), During the intake interview, patient #8 stated he rarely ate a meal and had to force himself to eat. The RN failed to identify rarely eating a meal as likely poor nutritional intake (score of 5). Patient #8 was screened with "No" nutritional problems. Patient #8 was not seen by the RD during his admission.

Further review revealed the following: Patient #10 was admitted voluntarily for alcohol detoxification. He was seen in the Emergency Department (ED) for blood in his stool on 10/16/2012 and was referred to the chemical dependency unit for detoxification. During his nursing intake, Patient #10 was given a High Risk Notification Alert for blood in his stool. The RN documented, in Part 1 of the Integrated Needs Assessment: problems related to appetite, Patient #10 stated "I hardly eat; don't wanna eat". The RN marked "decrease in appetite" but failed to identify the alcohol abuse with mal-absorption (score of 10) and poor intake and loss of appetite as "eating less than 50%" (score of 5). The Nutritional Risk Assessment revealed "No" problems. Patient #10 was not seen by the Registered Dietician (RD) during his admission.

Based on documents review, the nursing staff failed to identify and evaluate pt's needs and establish a nursing care plan, evaluate the intervention attempted on the plan, and failed to update the care plan as new problems developed and were identified during the patient's hospitalization and treatment for 9 (Patient # 1, #2, #3, #4, #5, #7, #8, #9, #10 ) of 13 patient's.


On 1/3/2013 in the conference room, the medical record (MR) for patient (Pt/pt) #1 revealed the following: Pt #1 was admitted 9/7/2012 with Psychiatric diagnosis of Major Depressive Disorder (MDD), Post Traumatic Stress Disorder (PTSD), not active at the time of admission and homeless. Her medical diagnoses were dictated in the History and Physical (H&P) as follows: Obesity, Sleep apnea, on CPAP machine (Continuous Positive Airway Pressure), Hypertension (HTN), Fibromyalgia. The Nursing assessment noted Gastric Bypass Surgery with 2 months of admission. A High Risk Notification Alert was identified with the following Alerts; Suicidal "Very Depressed", Medically Compromised "Post Gastric Bypass, Fibromyalgia, and HTN". The Nutritional Risk Assessment was reviewed and it identified Gastric Bypass Surgery July 2012 with a weight loss of 41 pounds since surgery. A review of the Multi Disciplinary Care (MDC)/ Interdisciplinary Treatment (IDT) plans, initiated upon admission (9/7/2012), were as follows:

Problem #1 Depressed. There was no target date identified and no resolution date identified. This problem was initiated 9/7/2012. The interventions were Physician assessment, suicide precautions, RN assessment, antidepressants, patient education. There were no changes or updates to these interventions.

Problem #2 was HTN. There was no target date identified and no resolution date identified. The intervention were admission lab, H&P, monitor vital signs (V/S), provide medication education including side effects. (no data found for this). There were no changes or updates identified.

Problem #3 was Pain. There was no target date identified and no resolution date identified. The interventions were: determine possible causes for pain, H&P, complete pain assessment upon admission and after each PRN (as needed) medication, provide comfort measures, instruct patient to report pain as soon as it begins, encourage relaxation exercises and diversional activities, assist patient to identify ways of avoiding/minimizing pain, give medications. There was no assessment to determine the cause for pain. There was evidence relaxation techniques were taught or encouraged.

Problem #4 was Gastrointestinal. There was no target date identified and no resolution date identified. The interventions were lab on admission, H&P, monitor V/S, provide medication education to include side effects. There were no adverse effects documented as taught and no changes or updates to the interventions.

The MDC was updated on 9/10, 9/12, 9/14, 9/17, 9/19 and 9/24. No target dates or resolution dates were noted. No new problems were noted. No new approaches were noted. No interpretation of the effectiveness of initial approaches were noted.
Pt #1 was discharged 9/25/2012.

On 1/3/2013 in the conference room, the MR for Pt #2 was reviewed and revealed the following: Pt #2 was admitted on 9/7/2012. The history and physical revealed an admitting psychiatric diagnoses of increased depression. Medical diagnosis as dictated in the H&P were listed as, history of spinal bifida and suprapubic catheter secondary to bladder surgery. The H&P did not identify a diagnosis for each of the medications listed upon admission. They included; Metoprolol, Hydrocodone, Docusate Sodium, Sumatriptan, Phenergan, Nitrofur, Lipitor, Lamictal, Seroquel, Tramadol and Oxybutynin. Pt #2 was positive for Cannaboid. Pt #2 had an elevated white blood count of 12.3 and a significantly low Vitamin D level of 19.2 (normal 30-100), testosterone serum of 34 (normal 348-1197) and free testosterone of 1.2 (normal 6.8- 21.5).

Review of the MDC revealed the following:

Problem #1 established 9/7/2012 was "altered mood, depressed with potential for self harm." Interventions were listed as: physician assessment, suicide precautions, RN assessment, antidepressants, patient education, and goal setting.

Problem #2 established 9/7/2012 was "Hypertension/Cardiac." The interventions were listed as: lab upon admission, H&P, monitor V/S, provide medication education including side effects. There was no evidence of nursing education for adverse effects.

Further review of pt #2 MR revealed he was placed on Bactrim DS for a urinary tract infection (UTI) that was multi-drug resistant. There was no nursing care plan for the UTI nor was there any evidence of precautions related to the multi-drug resistant bacteria in pt #2's urine. There was no nursing care plan for self care education, provision of catheter supplies or nursing interventions for pt #2's suprapubic catheter and use of leg bag.

The MDC was updated on 9/10, 9/12, 9/14, 9/17, 9/19 and 9/24. No target dates or resolution dates were noted. No new problems were noted. No new approaches were noted. No interpretation of the effectiveness of initial approaches were noted.
Pt #2 was discharged 9/25/2012.

On 1/3/2013 in the conference room, the MR for pt #3 was reviewed and revealed the following: Pt #3 was admitted on 8/31/2012 with a primary psychiatric diagnosis, as dictated in his H&P, of bipolar disorder with severe psychosis, methamphetamine abuse, and marijuana abuse. He had no medical diagnosis. His MDC was initiated on 8/31/2012.

Problem #1 was alteration in mood, potential for self harm. There were no target date identified and no resolution dates identified.

Problem #2 Out of Contact with Reality. There were no target dates identified and no resolution dates identified. There was no assessment of interventions noted.

On 1/3/2012 in the conference room the MR for Pt #4 was reviewed and revealed the following: Pt #4 was admitted on 10/29/2012 for a primary psychiatric diagnosis of MDD severe with psychotic features, PTSD, rule out panic disorder, generalized anxiety disorder as dictated in the H&P. Her medical diagnoses were listed as chronic constipation, HTN, and morbid obesity. A review of the MDC revealed the following problems and interventions established upon admission on 10/29/2012:

Problem #1 Out of contact with reality. A target date was identified for 11/3/2012. There was no resolution date identified.

Problem #2 Hypertension/Cardiac. This problem was identified "pt reports." The responsible staff failed to identify the admission H&P as the source of the diagnosis. Target dates are identified but no resolution date is identified. No other patient problem is identified on the IDT plan. No evaluation of intervention was identified.

Further review of Pt #4 MR revealed a low Vitamin D, 25-hydroxy level of 19 mg/ml (milligram per milliliter). Normal is 30-100 mg/ml. This was not identified on the MDC/IDT plan. The High Risk Notification Alert identified suicidal with multiple plans. No suicidal problem was identified and no interventions were identified in the MDC/IDT care plan. Sexual victimization was also listed in the alert. There was no MDC/IDT care plan identified and no interventions were identified. Auditory Command Hallucinations were also identified on the alert. There was no MDC/IDT care plan identified and no interventions identified. On Part 1: Integrated Needs Assessment Referral/Screening Assessment, pt #4 was documented as 5 feet 1 inches tall weighing 250 pounds. However, on the Compressive Assessment Tool Nursing Assessments pt #4 was documented as being 5 feet 2 inches tall and weighing 232 pounds. Pt #4 was documented above her BMI (Basic Metabolic Index). For her weight, pt #4 should have been 6 feet 3 inches tall. A review of the Nursing Nutritional Risk Assessment revealed pt #4 was screened with "NO" problems. No MDC/IDT care plan problem was initiated for nutritional needs and no intervention were documented for nutritional needs.

On 1/3/2012 in the conference room, the MR for pt #5 was reviewed and revealed the following: Pt #5 was admitted on 8/31/2012. Her primary psychiatric diagnoses was documented in the initial psychiatric evaluation as bipolar with mixed severe psychotic features. Her medical H&P listed History of Myocardial Infarct (MI). Recently admitted for 2 suicide attempts with acute respiratory failure requiring intubation. A review of her admission lab revealed positive urinary tract infection (UTI). A review of the High Risk Notification Alert revealed suicide, sexual victimization, self harm, medically compromised with "liver problems and history of MI," and chemical dependency withdrawal from cannabis. Pt #5 was documented as 5 feet 3 inches tall and weighing 145 pounds, 18.5 pounds above her IDB wt range. Review of the Nursing Nutritional Risk Assessment revealed "No" problems. Further review of Pt #5 MDC/IDT plan revealed the following:Problem #1 mood alteration with potential for harm. There was one short and one long term goal with no resolution date identified. No other problem was identified.

On 1/3/2012 in the conference room, the MR for Pt #7 was reviewed and revealed the following: Pt #7 was admitted on 1/1/13 with a primary psychiatric diagnosis of schizoaffective disorder. His primary medical diagnoses was HTN, gout, obesity, GERD (gastroesophogeal reflux disease) and restless leg syndrome. The comprehensive Nursing Assessment Tool reflects pt #7 was 6' tall and wt of 264 lbs. His BMI was above the high range of 213. He was admitted on a cardiac diet. The nutritional Risk Assessment was "No" problems. A review of his MDC/IDT revealed Problem #1, out of touch with reality. No resolution date was identified. Problem #2 was HTN with no resolution identified. Problem #3 was pain with no resolution date identified. No other problems were identified. Nutritional needs were not addressed.

On 1/3/2012 in the conference room, the MR for Pt #8 was reviewed and revealed the following: Pt #8 was admitted on 10/20/2012 with a primary psychiatric diagnosis of mood disorder, not otherwise specified, and medical diagnosis that included Traumatic Brain Injury secondary to a motor vehicle accident in 2008 . A review of his labs revealed his Vitamin D level was 12.6 (normal is 30-100). He was 6' tall and wt of 141.7 lbs. Pt #8 was 18.45 lbs below his lower ideal weight range (IDW).

A review of his MDC/IDT plan revealed the following:
Problem #1 was alteration in mood, depressed with potential for self harm. No short or long term goals were identified and no target date or resolution dates were identified.

Problem #2 was pain. No short or long term goals were identified and no target or resolution dates were identified.

Problem #3 was risk of fall. No short or long term goals were identified and no target or resolution dates were identified.

Problem #4 was potential for seizures with no short or long term goals and no target or resolution dates were identified.

On 1/3/2012 in the conference room, the MR for Pt #9 was reviewed and revealed the following: Pt #9 was admitted on 12/31/2012 with a primary psychiatric diagnoses of bipolar disorder, depressed with severe psychosis. Her medical diagnosis included Hyperthyroidism, cataracts, history of breast cancer. Review of her labs revealed a TSH (Thyroid Stimulating Hormone) of 7.1 (Normal 0.45-4.5) and a Valproic acid level of 124. (normal 50-100). Her urinalysis was positive for white blood cells (WBC) with WBC Esterase positive (normal is negative). The nursing High Risk Notification Alert identified suicide precautions, fall risk, and medically compromised thyroid condition.

Review of her MDC/IDT revealed the following:

Problem #1 alteration in mood depressed with potential for self harm. No long term or short term goal and no target dates of resolution dates were identified.

Problem #2 alteration mood manic/anxiety. No short term or long term goals were identified and no target or resolution dates were identified.

Problem #3 hypothyroidism. No short term or long term goals were identified and no target or resolution dates were identified. Pt #9 was placed on fall risk by the physician and also placed on Bactrim DS for a urinary tract infection (UTI). Evidence revealed Nursing staff failed to identify either of these two problems on the care plan and failed to assess pt #9 for either of these two problems during her hospitalization.

On 1/3/2012 in the conference room, the MR for Pt #10 was reviewed and revealed the following: Pt #10 was admitted on 10/16/2012 with a primary psychiatric diagnosis of alcohol dependence/withdrawal, MDD recurrent, severe without psychosis, and no medical diagnosis.

A review of the MDC/IDT care plan revealed problem #1 substance abuse with potential to detox. MDD was never addressed as a problem. None of the antipsychotropic drugs were added to the care plan (Trazodone, Ativan, Zoloft and Temazepam). On 10/17/2012 the Licensed Professional Counselor documented, "Pt admits to verbal abuse when drinking, continue treatment plan," However, there was no treatment plan for anger issues and verbal abuse.

Based on records review and interviews, the facility failed to insure medical staff signed and dated physician's orders/progress notes in 3 of 13( #11, #12, #13) patient records reviewed.

On 1/3/2013 in the conference room, the MR for the following patients were reviewed for completion of physician's orders and revealed:

Pt #11 had 15 unsigned physician's orders from medical staff member #3 and 9 unsigned physician's orders from medical staff #15.

Pt #12 had 1 unsigned progress note as well as the admission psychiatric medical assessment from medical staff #3 and one progress note from medical staff #15.

Pt #13 had greater than 10 unsigned progress notes from medical staff #3 and #15.

On 1/3/2013 in the conference room and interview with the Chief Executive Officer for the facility confirmed there was resistance and difficulty in getting the physicians to sign and date their documentation in a timely manner.