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Based on review of the facility policy and procedure, medical record review and staff interview, the facility staff failed to ensure vital signs were obtained per hospital policy for 4 of 10 sampled patient records (Patient #10, #1, #3 and #7); and failed to ensure the biopsychosocial assessments were completed per hospital policy for 2 of 10 sampled patient records (Patient #1 and #2).

Findings Included:

A. Review of the facility policy and procedure titled "Rehab Vital signs" effective May 01, 2018 revealed "Policy: ....to monitor vital signs on all patients at the Rehab LOC (level of care). Licensed nursing staff are the only personnel that will obtain vital signs. ...Vital signs are to be obtained: Upon admission and BID (twice a day) unless otherwise indicated by the medical provider ..."

Review of the facility policy and procedure titled "Detoxification Vital Signs" effective December 01, 2017 revealed "Policy: ....to monitor vital signs on all patients at the detox LOC (level of care). Licensed nursing staff and Certified nursing assistants are the only personnel that will obtain vital signs. ...Vital signs are to be obtained: Upon admission and TID (three times a day) unless otherwise indicated by the medical provider ..."

1. Review of the open medical record for patient #10 revealed a 43-year-old male admitted to the Detox level of care on 06/01/2018 with diagnoses of Alcohol Use Disorder, Tobacco Use Disorder, Anxiety Disorder and Bipolar Related Disorder. Review of the physician's verbal admission orders dated 06/01/2018 revealed an order for vital signs three times daily while in Detox and PRN (as needed). Review of the vital signs record for Patient #10 revealed vital signs documented on 06/01/2018 at 1202 and 1525; on 06/02/2018 at 0830, 1530 and 1959; on 06/03/2018 at 0749, 1516 and 1942; on 06/04/2018 at 0952, 1510 and 1947; and on 06/05/2018 at 0806 and 1515. Review of the medical record revealed no available documentation of a third set of vital signs obtained on 06/01/2018 and 06/05/2018.

Interview with Assistant Clinical Director on 06/06/2018 at 1000 during medical record review for Patient #10 revealed the facility policy states vital signs for patients admitted to the detox level of care should be obtained three times a day.

2. Review of the closed medical record for patient #1 revealed a 32-year-old male admitted to the Rehab level of care on 03/26/2018 at 1907 with diagnoses of Opioid Use Disorder, Cocaine Use Disorder, Tobacco Use Disorder and GSW (Gunshot wound) with TBI (Traumatic Brain Injury). Review of the record revealed patient #1 was discharged to the Partial Hospitalization Program on 04/05/2018. Review of the physician's verbal admission orders dated 03/27/2018 at 0459 revealed an order for vital signs three times daily while in Detox and PRN (as needed). Further review of the physician orders revealed no documentation of an order for vital signs for a patient admitted to the Rehab level of care. Review of the vital signs record for Patient #1 revealed vital signs documented on 03/26/2018 at 1915; on 03/27/2018 at 0805 and 2028; on 03/28/2018 at 0912 and 2050; on 03/29/2018 at 0658; on 03/30/2018 at 0741; on 03/31/2018 at 0729; on 4/02/2018 at 0719 and 2000; and 04/03/2018 at 0731 and 2005; on 04/04/2018 at 0651 and 1938. Review of the medical record revealed no available documentation of a second set of vital signs obtained on 03/29/2018, 03/30/2018 and 03/31/2018. Further review of the record revealed no available documentation of vital signs on 04/01/2018.

Interview with Assistant Clinical Director on 06/06/2018 at 0930 during medical record review for Patient #1 revealed the facility policy states vital signs for patients admitted to the rehab level of care should be obtained twice a day.

3. Review of the closed medical record for patient #3 revealed a 31-year-old male admitted to the Rehab level of care on 03/26/2018 with diagnoses of Opioid Use Disorder, Tobacco Use Disorder, Chronic right-hand pain s/p (status post) surgery and dental infection. Review of the record revealed patient #3 was discharged to the Partial Hospitalization Program on 03/30/2018. Review of the physician's verbal admission orders dated 03/26/2018 revealed an order for vital signs three times daily while in Detox and PRN (as needed). Further review of the physician orders revealed no documentation of an order for vital signs for a patient admitted to the Rehab level of care. Review of the vital signs record for Patient #3 revealed vital signs documented on 03/26/2018 at 2030; on 03/27/2018 at 0845 and 2004; on 03/28/2018 at 0811; and on 03/29/2018 at 2112. Review of the medical record revealed no available documentation of a second set of vital signs obtained on 03/28/2018 and 03/29/2018.

Interview with Assistant Clinical Director on 06/06/2018 at 0930 during medical record review for Patient #3 revealed the facility policy states vital signs for patients admitted to the rehab level of care should be obtained twice a day.

4. Review of the closed medical record for patient #7 revealed a 47-year-old female admitted to the Detox level of care on 01/22/2018 with diagnoses of Opioid Use Disorder, Amphetamine type substance abuse, Alcohol Use Disorder, Tobacco Use Disorder, Schizophrenia, Chronic back pain s/p (status post) surgery and Diabetes Mellitus. Review of the record revealed patient #7 was discharged to the Partial Hospitalization Program on 01/28/2018. Review of the physician's verbal admission orders dated 01/22/2018 revealed an order for vital signs three times daily while in Detox and PRN (as needed). Review of the vital signs record for Patient #7 revealed vital signs documented on 01/22/2018 at 1827 and 2243; on 01/23/2018 at 0841 and 1940; on 01/24/2018 at 0931 and 1900; on 01/25/2018 at 0942, 1231, 1530, 1730, 1800 and 2022; on 01/26/2018 at 0851 and 1530; and on 01/27/2018 at 1007 and 1530. Review of the medical record revealed no available documentation of a third set of vital signs obtained on 01/23/2018, 01/24/2018, 01/26/2018 and 01/27/2018.

Interview with Assistant Clinical Director on 06/06/2018 at 1000 during medical record review for Patient #7 revealed the facility policy states vital signs for patients admitted to the detox level of care should be obtained three times a day.

B. Review of the facility policy and procedure titled "Clinical Documentation" not dated, revealed " ... D. Clinical Formulation: The Biopsychosocial will be completed within 3 days of entering into REHAB level of care ..."

Review of the facility policy and procedure titled "Master Treatment Plan" not dated, revealed " ... Procedure: ...2. Master Treatment Plans are to be initiated within three days after admission/transition to rehabilitation ... level of care."

1. Review of the closed medical record for patient #1 revealed a 32-year-old male admitted to the Rehab level of care on 03/26/2018 at 1907 with diagnoses of Opioid Use Disorder, Cocaine Use Disorder, Tobacco Use Disorder and GSW (Gunshot wound) with TBI (Traumatic Brain Injury). Review of the record revealed patient #1 was discharged to the Partial Hospitalization Program on 04/05/2018. Review of the medical record revealed the biopsychosocial assessment was completed on 04/02/2018 at 1202 (7 days after admission). Review of the medical record revealed the treatment plan for Patient #1 was completed on 04/05/2018 (10 days after admission).

Interview with Assistant Clinical Director on 06/06/2018 at 0930 during medical record review for patient #1 revealed the facility policy states the biopsychosocial assessment and treatment plan should be completed within three (3) days of entering Rehab level of care.

2. Review of the closed medical record for patient #2 revealed a 50-year-old male admitted to the Rehab level of care on 03/26/2018 at 1627 with diagnoses of Alcohol Use Disorder, Cocaine Use Disorder, Cannabis Use Disorder and Tobacco Use Disorder. Review of the record revealed patient #2 was discharged to the Partial Hospitalization Program on 03/29/2018. Review of the medical record on 06/06/2018 revealed no available documentation of a completed biopsychosocial assessment in Patient #2's medical record.

Interview with Assistant Clinical Director on 06/06/2018 at 0930 during medical record review for patient #1 revealed the facility policy states the biopsychosocial assessment and treatment plan should be completed within three (3) days of entering Rehab level of care.

NC00137809, NC00138796

Based on hospital policy review, medical record review, and administrative staff interview, the hospital failed to administer a medication as prescribed in 1 of 4 patients (Patient #5) requiring medications.

Findings included:

Review of hospital policy titled "Medication Administration Part 1" effective date: 12/01/2017, revealed, "...Medications shall be administered or discontinued only upon the order from a member of the medical staff or other individuals who have been granted clinical privileges to write orders..."

Closed medical record review conducted on 06/05/2018 revealed Patient #5 was a 42-year-old female admitted to the facility on 01/22/2018 at 0955 with diagnoses of alcohol use disorder; sedative, hypnotic, or anxiolytic use disorder; and bipolar disorder. Review of admission orders, written by Medical Doctor #1 revealed, "...Phenobarbital (a potentially addictive medication that can be utilized to treat seizures) taper ... Date 2/2/18 ... Dose 30mg ..." Review of Patient #5's Medication Administration Record (MAR) revealed no evidence Patient #5 received a 30 mg dose of Phenobarbital on 02/02/2018.

Administrative staff interview conducted on 06/06/2018 at 0920 with the interim Chief Nursing Officer (CNO) confirmed the MAR revealed no evidence Patient #5 received any Phenobarbital on 02/02/2018. The CNO stated prior to administering Phenobarbital, staff nurses must sign a controlled substance log upon removing the medication from their medication cart. Interview revealed there was no evidence any Phenobarbital was removed from the medication cart for Patient #5 on 02/02/2018. The CNO advised the nurse assigned to Patient #5 no longer worked at the facility, and was unavailable for interview. Interview revealed the medication was not administered as ordered, and hospital policy was not followed.

NC00137809 , NC00138790