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Based on review of hospital policies and procedures, Medical Staff Rules and Regulations, Medical Staff Bylaws, medical record and interview, it was determined that the hospital failed to require the medical staff obtain documented informed consent for Psychotropic medications for two (2) of four (4) patients (Pt # 1, and # 4 ) who received psychotropic medication without documented consent of the patient or their representative as required by hospital policy which has a potential risk of harm to the patients of receiving medications not approved by the patient and /or Mental Health Power of Attorney (MHPOA).

Findings include:

Review of hospital policy titled "Informed Consent, Medication" revealed: "...It is the responsibility of the ordering practitioner to obtain the signed informed consent of the patient and/or legal representative...Informed consent will be secured prior to the initial dose of medication except in an emergency situation...The patient and /or legal representative will be provided with specific, complete and accurate information including...Name of medication, anticipated dosage and route...Reason the medication is being recommended...Benefits of the medication...Side effects or risk of side effects...Right to withdraw consent.... "

Review of hospital policy titled "Informed Consent" revealed: " ...All patients who have a psychotropic medication ordered and guardian of patients who have a psychotropic medication ordered will be informed of the benefits and risks involved in taking prescribed medication...Consent to take medications will be given in writing and witnessed by a licensed nurse, physician or pharmacist...The Physician will document the discussion in the Physician Progress Notes...The Nurse, Physician or Pharmacist will follow the process when medications are changed or added to those medication for which patient or as appropriate guardian had given consent...Licensed Nursing Staff Member, Physician, or Pharmacist will supply the patient guardian with benefit risk information about the new medication...The Nurse will write the new medication (s) in the space provided on the informed consent portion of the Medication Education Sheet.... "

Review of hospital policy titled "Patient Rights" revealed: " ...except in emergencies , the consent of the patient or their legally authorized representative, shall be obtained before treatment is administered.... "

Review of Pt #1's medical record revealed:

The medical record contained a form titled Informed Consent for Psychotropic Medication. Physician # 2 signed the form and documented consent obtained from the patient's daughter Mental health Power of Attorney (MHPOA) for four psychotropic medications: Seroquel, Depakote, Ativan and Celexa.

Patient # 1's Medication Administration Record revealed:

An RN administered Haldol 2.5 mg intramuscularly (IM) to patient # 1 on 12/8/14 at 2000 and again on 12/16/14 at 1545, for patient ' s agitation without the documented consent of the patient or patient's representative.

An RN administered Risperdal orally for agitation/psychosis 12/9/14 through 12/17/14, without documented consent of the patient or patient's representative.

Physician #1 confirmed during an interview conducted on 7/24/15, that he did not document consent for Risperdal and Haldol on the Informed Consent for Psychotropic Medication form and that he had not updated the consents for Patient #1.

Review of Patient #4's medical record revealed:

The medical record contained a form titled Informed Consent for Psychotropic Medication. Physician # 1 signed the form and documented consent obtained from the patient's spouse (MHPOA) for four psychotropic medications: Seroquel, Depakote, Tegretol and Klonopin.

Patient # 4 ' s Medication Administration Record revealed:

An RN administered Haldol 5 mg intramuscularly (IM) to patient # 4 on 8/20/14 at 2155, and again on 8/21/14 at 1130, for patient ' s agitation without the documented consent of the patient or patient's representative.

An RN administered Haldol 2.5 mg intramuscularly (IM) to patient # 4 on 8/21/14 at 0430, for patient ' s agitation without the documented consent of the patient or patient's representative.

An RN administered Ativan 2mg intramuscularly (IM) to patient # 4 on 8/2/14 at 0430, for patient ' s agitation without the documented consent of the patient or patient's representative.

An RN administered Risperdal orally for agitation on 8/20/14 without documented consent of the patient or patient's representative.

Physician #1 confirmed during an interview conducted on 7/24/15, that he did not document consent for Risperdal, Ativan and Haldol on the Informed Consent for Psychotropic Medication form and that he had not updated the consents for Patient #4.

The Director of Pharmacy confirmed in an interview conducted on 7/23/15, that all Psychotropic medications need to have informed consent. He also confirmed that Risperdal, Ativan and Haldol are Psychotropic medications.

The Director of Nursing confirmed in an interview conducted on 7/24/15, that all Psychotropic medications need to have informed consent. She also confirmed that Risperdal, Ativan and Haldol are Psychotropic medications.

Based on review of hospital policies/procedures, medical record and interview, it was determined that the hospital failed to require that the patient or her representative make informed decisions regarding the care for two (2) of four (4) patients (Pt # 1 and #4) who received psychotropic medication without documented consent of the patient or their representative as required by hospital policy which has a potential risk of harm to the patients of receiving medications not approved by the patient and /or Mental Health Power of Attorney (MHPOA).

Findings include:

Cross reference Tag 0049 for information regarding registered nurses administrating Psychotropic Medications without Informed consent from the patient or patient ' s representative.

RN # 9 confirmed in an interview conducted on 7/30/15, that all Psychotropic medications need an informed consent prior to administration. She also confirmed that if the informed consent has not been obtained, the medication needs to be held until the Informed Consent is obtained. She also confirmed that Risperdal, Ativan and Haldol are Psychotropic medications and need informed consent.

RN # 31 confirmed in an interview conducted on 7/30/15, that all Psychotropic medications need an informed consent prior to administration. She also confirmed that if the informed consent has not been obtained, the medication needs to be held until the Informed Consent is obtained. She also confirmed that Risperdal, Ativan and Haldol are Psychotropic medications and need informed consent.

The Director of Nursing confirmed in an interview conducted on 7/24/15, that all Psychotropic medications need to have informed consent prior to administration of the medications. She also confirmed that Risperdal, Ativan and Haldol are Psychotropic medications and these medications for Patient #1 and #4 were administered without Informed consent.

Based on review of hospital policy/procedure, hospital documents, nursing assignment sheets and interview, it was determined that nursing services failed to provide adequate numbers of nursing personnel as per facility policy. Failure to obtain the required nursing staff has the potential to cause the patient harm by not meeting the patient's physical and mental health needs.

Findings include:

Hospital policy titled Assignment of Nursing Staff requires: "...Patient care assignment is commensurate with the qualifications of each nursing staff member and the identified nursing need of the patient according to acuity. Patient care assignment is based on acuity and equally distributed among staff...Staff who are assigned to a patient who is on 1:1...will not be assigned any other responsibility during the time they are assigned to the 1:1...."

The Acuity and Assignment policy requires: "... Level 1: Line of sight...1:1 ordered... recent suicide... impulsive... agitated...Level 2: Mildly psychotic... needs frequent redirection... moderate assistance...medical problems/symptoms requiring frequent monitoring...Independently performs ADL's... routine supervision...minimal staff intervention...DAYS/EVES RN-three level (1), eight level (2), one, Level(sp) (3)...BHT-two level (1), five level (2), three level (3)...NIGHTS...RN-three level (1), ten level (2) one, Level (sp) (3) BHT-three level (1), ten level (2), one level (3)...."

The policy requires the maximum acuity score of the RN on the day/evening shift shall be 22 and the maximum acuity score of the BHT on the day/evening shift shall be 21. There is no acuity score assigned for LPN's for any shift.

The policy requires the maximum acuity score of the RN on the night shift shall be 26 and the maximum acuity score of the BHT on the night shift shall be 26. There is no acuity score assigned for LPN's for any shift.

Assignment Sheet Day Shift dated 01/12/14, revealed: the first nurse was assigned 14 patients with an acuity score of 26, and the second nurse was assigned 14 patients with an acuity score of 26. According to the Acuity and Assignment sheet the maximum acuity score for the Day RN's is 22.

Assignment Sheet Day Shift dated 01/12/14, revealed: the fifth BHT was assigned two (2) patients with an acuity score of 2, however, both patients are assigned as 1:1.

Assignment Sheet Evening Shift dated 01/12/14 revealed: the fifth BHT is assigned two 1:1's.

Assignment Sheet Night Shift dated 01/12/14 revealed: two RN's were assigned 15 patients each with an acuity scores of 28 and 30. According to the Acuity and Assignment sheet the maximum acuity score for Night RN's is 26.

The Director of Nursing confirmed during an interview conducted on 07/30/15, that the acuity score is determined by adding all patient levels together. The Director confirmed all three (3) shifts on 01/12/14, did not adequately staff the nursing unit per hospital policy.

Based on review of hospital policy/procedure, hospital documents, medical records and interviews, it was determined that the administrator failed to ensure that a registered nurse must supervise and evaluate the nursing care for each patient by

1. Failing to ensure that the informed consent for Psychotropic medications was obtained prior to administration of Psychotropic Medications for two (2) of four (4) patients (Patient #1 and #4) which has a potential risk of harm to the patients of receiving medications not approved by the patient and /or Mental Health Power of Attorney (MHPOA);

2. Failing to ensure that administration of medications or treatments ordered by a physician are completed as ordered for one (1) of one (1) patients (Patient # 9) which has the potential risk of harm to the patient if they are not provided with the ordered hydration necessary to prevent dehydration in the elderly population;

3. Failing to ensure that administration of medications or treatments ordered by a physician are completed as ordered for one (1) of one (1) patients (Patient # 3 ) which has the potential risk of harm to the patient if they are not provided with the ordered nutrition supplements necessary to prevent malnutrition in the elderly population; and

4. Failing to ensure that the patient's weight was obtained and documented per physician orders for one (1) of one (1) patients (Patient #3) which has the potential risk of harm to the patient for a large weight loss causing malnutrition.

Findings include:

1. Cross reference Tag 0049 for information regarding registered nurses administrating Psychotropic Medications without Informed consent from the patient or patient ' s representative.

RN # 9 confirmed in an interview conducted on 7/30/15, that all Psychotropic medications need an informed consent prior to administration. She also confirmed that if the informed consent has not been obtained, the medication needs to be held until the Informed Consent is obtained. She also confirmed that Risperdal, Ativan and Haldol are Psychotropic medications and need informed consent.

RN # 31 confirmed in an interview conducted on 7/30/15, that all Psychotropic medications need an informed consent prior to administration. She also confirmed that if the informed consent has not been obtained, the medication needs to be held until the Informed Consent is obtained. She also confirmed that Risperdal, Ativan and Haldol are Psychotropic medications and need informed consent.

The Director of Nursing confirmed in an interview conducted on 7/24/15, that all Psychotropic medications need to have informed consent prior to administration of the medications. She also confirmed that Risperdal, Ativan and Haldol are Psychotropic medications and these medications for Patient #1 and 4 were administered without Informed Consent.

2. Review of hospital policy titled Hydration & I&O revealed: " ...The purpose of this procedure is to accurately determine the amount of liquid a patient consumes in a 24-hour period if ordered...to ensure patient's are offered adequate amount of fluids throughout the day to maintain hydration...It is important that all patients are offered fluids throughout the day to ensure they maintain proper hydration...record the fluid intake as soon as possible after the patient has consumed the fluids...Every two hours ensure to offer each patient the hydration opportunity...Record the amount noted on the intake side of the intake and output record...If the patient refused the offer of fluids the RN is to document this in the RN progress notes...."

Review of hospital policy titled Documentation Protocol revealed: "...All medical records are to be accurate, truthful, and complete...Staff are to document accurately our services provided, patient interactions...Every staff who creates or reviews documentation in a medical record or responds to or implements orders or directives contained in a medical record, ensure that the medical record complies with this Documentation Protocol...To assure accurate and timely documentation...."

Review of Pt #9's medical record on 7/21/15, revealed that MD # 3 wrote an order for "...Push H2O (sic) 500 ml PO TID..." The medical record revealed that there was no order to discontinue the water 500 ml three times a day.

Review of the medical record revealed that the order for Hydration was carried out on 7/21/15 and 7/22/15. After 7/22/15, there was no documentation available for review that the order for 500 ml of water three times a day was being given to the patient.

RN # 9 confirmed in an interview conducted on 7/30/15, that when water flushes are ordered by the Physician the order is transcribed on the Medication Administration Record.

RN # 31 confirmed in an interview conducted on 7/30/15, that when water flushes are ordered by the Physician the order is transcribed on the Medication Administration Record. RN # 31 also confirmed that she did not think Patient # 9 had an order for hydration. She also confirmed that she is assigned to care for Patient # 9 today and has taken care of her several times since the patient was admitted.

The DON confirmed in an interview conducted on 7/30/15 that there was no documentation in the medical record that this hydration order was implemented after 7/22/15.

3. Physician orders dated 01/08/14 revealed: one (1) can boost three (3) times per day and one (1) can Ensure clear three (3) times per day.

Review of the Medication Administration Record (MAR) dated 01/14/14 and 01/15/14 revealed: nutritional Boost and Clear Ensure was initialed by nursing staff as given at 0800, 1200 and 1700.

The Graphic record dated 01/07/14 through 01/17/14 revealed: INTAKE nutritional supplement box without any documentation of the patient's intake, except for the following dates: 01/11/14, 01/13/14 and 01/14/14.

The Director of Nursing confirmed during an interview conducted on 07/24/15 that the Graphic Record nutritional supplement is to be documented with the fluid intake. There was no documentation of the fluid intake for nutritional supplement except for the above dates.

4. Physician Orders dated 01/08/14 revealed: weekly weights. Physician orders dated 01/14/14 revealed weights every 3 days.

The patient's weight was documented on the Graphic record on 01/07/14 at 125 pounds upon admission. Physician orders dated 01/14/14, confirmed "weights every 3 days." The last recorded weight of the patient was completed on 01/12/15 at 112 pounds. There was no documentation the patient was weighed on 01/15/14 or any time after. The patient was discharged 01/17/14.

The Director of Risk Management and the Director of Nursing confirmed during interviews conducted on 07/24/15 that the patient's weight was documented on the Graphic record on 01/07/14 and 01/12/14.

Based on review of policies and procedures, facility documentation, and interview, it was determined that the hospital failed to ensure that the hospital's dietary personnel were competent in their respective duties as evidenced by failing to assure that foods were served to patients at appropriate temperatures to avoid potential food-borne illness and risk of harm to the patients.


Findings include:

Review of the dietary policy and procedure titled " Food Service Standard of Practice - Tray Service Temperatures" revealed that the test tray evaluations shall meet food temperature ranges established in temperature ranges found on the form...If these ranges are not met, an action plan shall be established to ensure future compliance...This action plan will include more frequent tray checks to establish temperature consistency...."

Review of the facility documentation of the test trays revealed in April 2015, hot foods meet temperature standards when patients receive meals 0%, with a goal of 100%; May 2015, hot foods meet temperature standards when patients receive meals 0%, with a goal of 100%; June 2015, hot foods meet temperature standards when patients receive meals 33%, with a goal of 100%; and July 2015, hot foods meet temperature standards when patients receive meals 50%, with a goal of 100%.

The April documentation revealed that corrective action was needed, however there was no documentation of what the corrective action would be. There was no documentation of a repeat of the hot foods meet temperature standards when patients received meals during the month of April.

The May documentation revealed that corrective action was needed of not starting the tray line until 30 minutes prior to the meal times to ensure temperatures are at acceptable ranges upon delivery to the patients. There was no documentation of a repeat of the hot foods meet temperature standards when patients received meals during the month of May after the corrective action.

The June documentation revealed that corrective action that the steam table still needs to be fixed to help with the hot food temperature. There was no documentation of a repeat of the hot foods meet temperature standards when patients received meals during the month of June.

The July data dated 7/19/15, revealed the heating equipment was still needing repair. There was no documentation of a repeat of the hot foods meet temperature standards when patients received meals after the heating equipment was repaired on 7/20/15. Dietary Manager # 25 confirmed in an interview conducted on 7/30/15 that the heating equipment was not working properly since he started at the facility about three weeks ago. He stated the part did not come in and the heating unit was repaired on 7/19/15. He also confirmed that appropriate food temperatures are important.

The Director of Risk Management and Quality confirmed in an interview conducted on 7/30/15 that the heating equipment was not working properly since the kitchen moved up to the second floor about two months ago. She also confirmed that the test tray data revealed that the 50 % score for July was not meeting standards, that temperatures not being in range can place the patients at risk; and also that there was no documentation of a repeat of the hot foods meet temperature standards when patients received meals after the heating equipment was repaired on 7/20/15.

Based on review of hospital policy/procedure, medical records and interviews, it was determined that the administrator failed to ensure that the patient received a Dietitian consult as ordered by the physician for one (1) of one (1) patients (Patient #3). Failure of the Dietitian assessment may place the patient at risk for malnutrition.

Findings include:

Hospital policy titled Dietary Services requires: "...Diet orders will be obtained through the physician...clarifications will be made through the Registered Dietitian..."

Physician order's dated 01/08/15 at 1425 hours revealed: Diet consult.

Physician #3 confirmed during an interview conducted on 07/23/15, that she had ordered a diet consult with additional nutritional supplements and fluids upon the patient's admission.

The Registered Dietitian and the Risk Manager confirmed during interviews conducted 07/28/15, that the medical record did not contain a dietary consult.

Based on a review of policy and procedure, review of medical record for Patient # 5, and interview it was determined the administrator failed to require the staff discharging the patient hand off the current patient status to the receiving facility, as per policy or communicate with family prior to the patient discharge, which is a potential health and safety risk that the needs of the patient will not be addressed.

Findings include:

Review of hospital policy - Discharge/Aftercare Plan PolicyStat ID 1663658 revealed: On page 2 of 4 "...Include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care (i.e.: PCP, skilled nursing facility, therapists,etc.)...On Page 4 of 4 Discharge Process and Responsibilities: Nurse to Nurse with receiving facility, if applicable...."

Review of medical record for Patient # 5 identified that there was no documentation of a "hand off" communication with the accepting facility upon discharge.

Employee # 9 confirmed in an interview on 07/30/2015 at 1010, there is no documentation present in the medical record of a report being called to the receiving Adult Living Facility or to the patient representative regarding the patient condition upon discharge.

The facility failed to "hand off" the current patient status prior to transfer to an adult living facility or communicate with the patient family prior to discharge.