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Based on observation, record review, policy review, document review and interview, the Hospital failed to protect and promote each patient's rights. Failure to protect and promote each patient's rights has the potential to places patients at risk for harm, injury, and adverse outcomes, including death.

Findings Include:

1. The Hospital failed to ensure that 5 of 5 patients reviewed (Patient 1, 2, 3, 4, and 5) were involved in the development and implementation of their plan of care. (Refer to tag A-0130).

2. The Hospital failed to ensure the right to make informed decisions including admission, psychotropic medications, and other treatment decisions for 5 of 5 patients reviewed (Patient 1, 2, 3, 4, and 5) (Refer to tag A-0131)

3. The Hospital failed to ensure 5 of 5 patients reviewed (Patient 1, 2, 3, 4, and 5) received care in a safe setting through failure to minimize ligature risks, perform safety checks, and ensure that contraband items were removed from the unit. (Refer to tag A-0144)

4. The Hospital failed to ensure three of five patients reviewed (Patient 2, 4, and 5) were afforded their right to have visitors. (Refer to tag A-0216)

Based on policy review and record review the Hospital failed to ensure that 5 of 5 patients reviewed (Patient 1, 2, 3, 4, and 5) were involved in the development and implementation of their plan of care. This deficient practice has the potential to cause harm and other adverse outcomes.

Findings Include:

Review of the Hospital's policy titled, "Treatment Team Protocol," dated 07/2022, showed, "The treatment team is a meeting of the interdisciplinary treatment team: Director of Behavioral Health, Nurse Manager, Social Worker/Therapist (SW), certified recreational therapist or activity therapist and physician. The purpose of the meeting is for developing an individualized treatment plan. The first team meeting occurs no later than 72 hours after admission. Subsequent team meetings for reviewing and updating the treatment plan occur at least every seven (7) days or more often as it is clinically indicated . . . Patient and family involvement in treatment planning is expected and encouraged. Other persons may be invited as deemed appropriate by the team and the patient. Each team member participating in the team planning is responsible for having completed and documented his or her assessment . . . the attending psychiatrist directs the patient care and guides the team. The social worker or Case manager will see that the patient is an actively involved in the treatment planning process as clinically appropriate and will be responsible for explaining the plan to the patient and getting the patient's signature on it. The Director of Behavioral Health may decide to have the Case Manager/Clinical Social Worker/Nurse in consultation with other members of the treatment team, develop a proposed master treatment plan prior to staffing. The social worker or case manager shall complete the weekly staffing/continued stay summary based upon team input . . . The treatment plan review will identify and a brief descriptive, measurable summary of patient's progress or lack thereof for each short-term goal. The individual treatment plan will reflect change in target date, interventions and/or short-term goals to enable patient to achieve their treatment goals."


Patient 1

Review of Patient 1's current medical record showed that Patient 1 was voluntarily admitted on 08/17/22 after attempting a suicide by overdosing on oxycodone (a medication used to treat pain). Patient 1 has the following diagnoses: fibromyalgia (disorder that affects muscle and soft tissue characterized by chronic pain that causes tenderness, fatigue, and sleep disturbances), angina (chest discomfort or shortness of breath when heart muscles receive insufficient oxygen-rich blood), diabetes (high blood sugar levels for extended periods of time), hypothyroid (decrease in production of thyroid hormones), deep vein thrombosis (DVT) (clotting deep inside the veins, usually the thighs and lower legs), and depression (persistent sadness and lack of interest or pleasure in once enjoyable activities).

Review of Patient 1's medical record failed to document evidence of the patient or patient's guardian's involvement in treatment team meetings or the treatment plan's development as evidenced by obtaining the patient's signature as outlined in the hospital's policy.


Patient 2

Review of Patient 2's discharged medical record showed that Patient 2 was involuntarily admitted on 08/17/22 due to active psychosis and hallucinations that lead to calling the police repetitively and then not allowing the police to assist her or enter her room at the nursing home. Patient 2 has the following diagnoses: history of left temporal intracranial bleed (bleeding of the brain), morbid obesity, insomnia (difficulty falling and staying asleep), dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), depression, and hypertension (high blood pressure). Patient 2 was discharged on 08/30/22.

Review of Patient 2's medical record failed to document evidence of the patient or patient's guardian's involvement in treatment team meetings or the treatment plan's development as evidenced by obtaining the patient's signature as outlined in the hospital's policy.


Patient 3

Review of Patient 3's discharged medical record showed that Patient 3 was admitted after being found wandering in a corn field and after interactions with law enforcement due to bizarre behavior. Patient 3 has the following diagnoses: Parkinson's Disease (a chronic and progressive movement disorder that initially causes tremor, stiffness, or slowing of movement), Schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thought and behaviors), insomnia, anxiety (the mind and body's response to stressful, dangerous, or unfamiliar situations, that leave a sense of uneasiness, distress, or dread), gastroesophageal reflux disease (GERD) (a chronic digestive disease where the liquid content of the stomach refluxes into the throat), and depression. Patient 3 was discharged on 08/30/22.

Review of Patient 3's medical record failed to document evidence of the patient or patient's guardian's involvement in treatment team meetings or the treatment plan's development as evidenced by obtaining the patient's signature as outlined in the hospital's policy.


Patient 4

Review of Patient 4's discharged medical record showed that Patient 4 was voluntarily admitted on 08/18/22 after displaying suicidal ideation and increased difficulties of performing activities of daily living (ADLs). Patient 4 has the following diagnoses: anxiety disorder, bipolar disorder (a serious mental illness characterized by extreme mood swings), diabetes, insomnia, GERD, hyperlipidemia (high cholesterol), and hypertension. Patient 4 is suspected to have dementia. Patient 4 was discharged 08/30/22.

Review of Patient 4's medical record failed to document evidence of the patient or patient's guardian's involvement in treatment team meetings or the treatment plan's development as evidenced by obtaining the patient's signature as outlined in the hospital's policy.


Patient 5

Review of Patient 5's current medical record showed that Patient 5 was involuntarily admitted on 08/19/22 after breaking into her chiropractor's office building. Patient 5 was admitted to her local hospital and increasingly became more physically and verbally abusive toward staff and refusing treatment. Patient 5 has the following diagnoses: unspecified dementia, mood disorder (general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function), and hypertension.

Review of Patient 5's medical record failed to document evidence of the patient or patient's guardian's involvement in treatment team meetings or the treatment plan's development as evidenced by obtaining the patient's signature as outlined in the hospital's policy.


During an interview on 09/01/22 at 10:49 AM, Staff E, Medical Doctor (MD), stated that treatment teams are still evolving, eventually they would get it together, and eventually have families attend. Staff E stated that treatment team is once a week and it's documented in a note. The family would be invited by the social worker. We are in a state of flex right now. We are learning what we are supposed to be doing.

Based on policy review, document review, record review, and interview, the Hospital failed to ensure the right to make informed decisions including admission, psychotropic medications, and other treatment decisions for 5 of 5 patients reviewed (Patient 1, 2, 3, 4, and 5). This deficient practice has the potential for incapacitated adults consenting to admission and treatments that they do not understand leading to harm or other adverse outcomes.

Findings Include:

Review of the Hospital's policy titled, "Informed Consent for Psychiatric Treatment," dated 07/2022, showed, "It is the policy of the senior healthcare unit of [Hospital] that all persons who meet criteria for admission will be assessed to determine if they are capable of giving informed consent for psychiatric treatment. If they are assessed to be capable, they will be allowed to sign a consent specific to psychiatric treatment, giving permission for psychiatric treatment. A legal guardian/DPOA may also sign the patient in on voluntary status per state standards. If a patient is assessed to be incapable of giving informed consent, they will either not be admitted or if they meet criteria, an application will be made for involuntary treatment per state requirements."

Review of the Hospital's policy titled, "Documentation of Legal Status," dated 07/2022, showed, "The legal status (i.e., voluntary, or involuntary) of the patient will be determined prior to admission and will be documented . . . the patient's legal status will be determined prior to the initiation of treatment."

Review of the Hospital's "Inquiry, Pre-Admission Assessment," form showed a form that collected the referring facility's information, patient demographics, pre-admission assessment, and disposition and status which includes space to identify voluntary or involuntary admission.

Review of the document "Stain Louis University Mental Status (SLUMS) Examination)," showed a psychometric screening tools for detecting mild cognitive impairment and dementia. Further review showed a score of 27 - 30 is considered normal. A score of 21 - 26 is considered a mild neurocognitive disorder. A score of 1 - 20 shows dementia is present.


During an interview on 09/01/22 at 12:26 PM, Staff F, Doctor of Nursing Practice (DNP), stated that she works with the psychiatric nurse with admissions and discharges. Staff F stated that a SLUMS score of 20 or under requires a patient to have a DPOA (Durable Power of Attorney). Staff F stated that you must rely on the truthfulness of the referring provider stating that they have the DPOA paperwork. We ask now if there is a copy of the document. Staff F verified that the DPOA paperwork must be notarized.


Patient 1

Review of Patient 1's current medical record showed that Patient 1 was voluntarily admitted on 08/17/22 after attempting a suicide by overdosing on oxycodone (a medication used to treat pain). Patient 1 has the following diagnoses: fibromyalgia (disorder that affects muscle and soft tissue characterized by chronic pain that causes tenderness, fatigue, and sleep disturbances), angina (chest discomfort or shortness of breath when heart muscles receive insufficient oxygen-rich blood), diabetes (high blood sugar levels for extended periods of time), hypothyroid (decrease in production of thyroid hormones), deep vein thrombosis (DVT) (clotting deep inside the veins, usually the thighs and lower legs), and depression (persistent sadness and lack of interest or pleasure in once enjoyable activities).

Review of Patient 1's "Inquiry, Pre-Admission Assessment," completed on 08/16/22 at 12:16 PM by Staff N, Licensed Professional Counselor (LPC), showed that Part C, Disposition and status was not completed. The assessment was not reviewed or signed by the attending physician.

Review of Patient 1's "SLUMS Examination," showed a score of 20 (a score of 20 or less requires a patient to have a DPOA).

Review of Patient 1's "Consent for Voluntary Admission," showed that Patient 1 signed her own consent on 08/17/22.


Patient 2

Review of Patient 2's discharged medical record showed that Patient 2 was involuntarily admitted on 08/17/22 due to active psychosis and hallucinations that lead to calling the police repetitively and then not allowing the police to assist her or enter her room at the nursing home. Patient 2 has the following diagnoses: history of left temporal intracranial bleed (bleeding of the brain), morbid obesity, insomnia (difficulty falling and staying asleep), dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), depression, and hypertension (high blood pressure). Patient 2 was discharged on 08/30/22.

Review of Patient 2's "Inquiry, Pre-Admission Assessment," completed on 08/16/22 at 11:03 AM by Staff N, LPC, showed that Part C, Disposition and status was not completed. The assessment was not reviewed or signed by the attending physician.

Review of Patient 2's "SLUMS Examination," showed a score of 20 (a score of 20 or less requires a patient to have a DPOA).

Review of Patient 2's "Consent for Voluntary Admission," showed that Patient 2 signed the consent on 08/17/22.


Patient 3

Review of Patient 3's discharged medical record showed that Patient 3 was admitted after being found wandering in a corn field and after interactions with law enforcement due to bizarre behavior. Patient 3 has the following diagnoses: Parkinson's Disease (a chronic and progressive movement disorder that initially causes tremor, stiffness, or slowing of movement), Schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thought and behaviors), insomnia, anxiety (the mind and body's response to stressful, dangerous, or unfamiliar situations, that leave a sense of uneasiness, distress, or dread), gastroesophageal reflux disease (GERD) (a chronic digestive disease where the liquid content of the stomach refluxes into the throat), and depression. Patient 3 was discharged on 08/30/22.

Review of Patient 3's "Inquiry, Pre-Admission Assessment," completed on 08/16/22 at 10:40 AM by Staff N, LPC, showed that Disposition and status was not completed. The assessment was not reviewed or signed by the attending physician.

Review of Patient 3's "Durable Power of Attorney for Health Care Decisions," showed that Patient 3 signed the form on 08/05/22. The form is not notarized by a Notary Public.

Review of Patient 3's "SLUMS Examination," showed a score of 11 (a score of 20 or less requires a patient to have a DPOA).

Review of Patient 3's "Consent for Voluntary Admission," showed that Patient 3 signed the consents on 08/17/22 at 5:50 PM.


Patient 4

Review of Patient 4's discharged medical record showed that Patient 4 was voluntarily admitted on 08/18/22 after displaying suicidal ideation and increased difficulties of performing activities of daily living (ADLs). Patient 4 has the following diagnoses: anxiety disorder, bipolar disorder (a serious mental illness characterized by extreme mood swings), diabetes, insomnia, GERD, hyperlipidemia (high cholesterol), and hypertension. Patient 4 is suspected to have dementia. Patient 4 was discharged 08/30/22.

Review of Patient 4's "SLUMS Examination," showed a score of 16 (a score of 20 or less requires a patient to have a DPOA).

Review of Patient 4's "Consent for Voluntary Admission," showed that Patient 4's family member provided verbal consent on 08/23/22, 5 days following admission.


Patient 5

Review of Patient 5's current medical record showed that Patient 5 was involuntarily admitted on 08/19/22 after breaking into her chiropractor's office building. Patient 5 was admitted to her local hospital and increasingly became more physically and verbally abusive toward staff and refusing treatment. Patient 5 has the following diagnoses: unspecified dementia, mood disorder (general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function), and hypertension.

Review of Patient 5's "SLUMS Examination," showed a score of 19 (a score of 20 or less requires a patient to have a DPOA).

Review of Patient 5's "Consent for Voluntary Admission," showed that family (F), F2, DPOA, signed on 08/20/22.


During an interview on 09/01/22 at 1:48 PM, Staff B, Director of Risk Management and Quality, stated that consents should be handled by the DPOA or guardian, but is unsure how the determination of whether a patient requires a guardian or DPOA. Staff B stated that the hospital's responsibility would be to obtain consent legally before doing anything and that the patient would stay where they were while it was obtained. Staff B stated in the past the DPOA paperwork would come from the sending facility and should be included with the paperwork sent with the patient. Staff B stated that she is unsure how to determine whether a guardianship form is legal. Staff B then stated that the DPOA form had to be notarized and signed by the person when they had capacity. Staff B stated that if the form is not notarized it is not a legal document. Staff B states that admission and treatment consents should be signed prior to any treatment or medication.

Based on observation, policy review, document review, record review, and interview the Hospital failed to ensure 5 of 5 patients reviewed (Patient 1, 2, 3, 4, and 5) received care in a safe setting through failure to minimize ligature risks, perform safety checks, and ensure that contraband items were removed from the unit. This deficient practice has the potential to cause harm and other adverse outcomes, including death.


Findings Include:


Review of the Hospital's policy titled, "Suicide Assessment and Prevention," dated 07/2022, showed, "It is the responsibility of all staff to maintain a safe and therapeutic milieu for all patients at all times. Environmental rounds are to be conducted with each 15-minute check, as well as daily. In addition, all staff is to be continually aware of the environment and immediately correct or report any identified risks, damage, missing linens, or any other change in the environment to their supervisor or Plant Operations personnel for immediate mitigation." Further review showed, "All patients will be monitored at least every 15-minutes."

Review of Hospital's document titled, "Unit Staff Competency Validation," dated 03/26/19, showed that orientation to the behavioral health unit includes the following task: "Become familiar with Environmental/Safety Checks and monitor daily for completion. If there are any items identified, ensure that they are communicated to the PD [Program Director] or NM [Nurse Manager] immediately. Safety checks should be completed every shift with the evening shift check being completed following visitation. Review the current form used."

Review of the Hospital's document titled, "Patient Observation Rounds," showed a one-page document that included monitoring level, precautions, behavior codes, and location codes. Each hour from midnight through the end of the day allowing for five opportunities of observations. Each observation documents time, behavior, location, and the initials of the staff making the observation. At the bottom of the sheet is a place for the charge nurse to review, time, and sign. Below that allows for staff completing the observations to sign and provide initials for comparison.

Observation made on 08/30/22 at 1:30 PM showed the following safety concerns:

1. Patient rooms were not numbered and pose as a risk of staff entering the wrong room to provide treatment or cares.

2. The first room to the left had a loose toilet seat, which may lead to a fall or injury.

3. The bedrooms had small chairs and bedside tables that were not secured to the ground and could pose as weapons.

4. The hospital beds in all the rooms had cords that pose as ligature risks.

5. Staff O, Registered Nurse (RN) was observed in the third patient room on the left, picking up a pair of sweat pants off the counter. The room was open and unlocked and the pants were accessible to all patients. The surveyor noticed that the pants had a draw string. The surveyor checked the draw string and noticed that it was a full-length cord that could be used as a ligature. During an interview at the time of the observation, Staff O, RN, stated that patient should not have pants with laces in them. She stated that she had put them there because they just came out of the laundry and she had to put them away into the locked closet.

6. The curtains in the third patient room to the left were observed to have three safety pins securing the Velcro pull-away tabs together. The safety pins pose as sharps that could be used to commit suicide, self-harming behaviors, or as a weapon against others.

7. The sink in the hallway has a 'U' shaped pipes that were exposed and posed as a ligature risk.

8. The outlets in the hallway did not have safety screws. The screws pose a risk for self-harming or suicidal behaviors.

9. There was a metal square on the wall by the first patient room to the left. This metal square had sharp corners and posed as a self-harming risk.

10. The staff bathroom was found to be unlocked and accessible to all patients. It was noted that a plastic bag lined the trash can and poses as a suffocation or ligature risk to patients. At the time of the observation, Staff O, RN, stated that the bathroom should be locked at all times and accessible only to staff.

11. Observation in the common area showed a large tablet that was unsteady and poses a risk of injury to patients who may use the table to steady their gate or rise from a chair.

12. The chairs in the common area were gliders and did not appear to lock and pose as a fall hazard as patients sat down or stood up from them.

13. Further observation in the common area showed bedside tables on wheels that pose as a fall risk if used by a patient to steady their gait.

14. All outlets on the unit were open and exposed to patients, posing as an electric shock risk.

15. Observation of the sink in the common area showed that linoleum was coming off the side of the sink. Pieces of linoleum could be fashioned into weapons or sharps posing harm to others and self.

Patient 1

Review of Patient 1's current medical record showed that Patient 1 was voluntarily admitted on 08/17/22 after attempting a suicide by overdosing on oxycodone (a medication used to treat pain). Patient 1 has the following diagnoses: fibromyalgia (disorder that affects muscle and soft tissue characterized by chronic pain that causes tenderness, fatigue, and sleep disturbances), angina (chest discomfort or shortness of breath when heart muscles receive insufficient oxygen-rich blood), diabetes (high blood sugar levels for extended periods of time), hypothyroid (decrease in production of thyroid hormones), deep vein thrombosis (DVT) (clotting deep inside the veins, usually the thighs and lower legs), and depression (persistent sadness and lack of interest or pleasure in once enjoyable activities).

Review of Patient 1's "Patient Observation Rounds," showed that the following 15-minute safety checks were not completed:

08/19/22 - 5:45 AM and 12:45 PM through 1:45 PM
08/22/22 - 2:56 AM, 6:53 AM, and 11:45 AM
08/23/22 - 12:37 PM through 2:00 PM and 3:45 PM
08/26/22 - 5:45 AM, 9:45 AM, and 11:45 AM


Patient 2

Review of Patient 2's discharged medical record showed that Patient 2 was involuntarily admitted on 08/17/22 due to active psychosis and hallucinations that lead to calling the police repetitively and then not allowing the police to assist her or enter her room at the nursing home. Patient 2 has the following diagnoses: history of left temporal intracranial bleed (bleeding of the brain), morbid obesity, insomnia (difficulty falling and staying asleep), dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), depression, and hypertension (high blood pressure). Patient 2 was discharged on 08/30/22.

Review of Patient 2's "Patient Observation Rounds," showed that the following 15-minute safety checks were not completed:

08/17/22 - 3:15 PM and 6:00 PM
08/22/22 - 2:05 AM and 6:50 AM
08/23/22 - 12:45 PM, 2:00 PM, and 5:55 PM


Patient 3

Review of Patient 3's discharged medical record showed that Patient 3 was admitted after being found wandering in a corn field and after interactions with law enforcement due to bizarre behavior. Patient 3 has the following diagnoses: Parkinson's Disease (a chronic and progressive movement disorder that initially causes tremor, stiffness, or slowing of movement), Schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thought and behaviors), insomnia, anxiety (the mind and body's response to stressful, dangerous, or unfamiliar situations, that leave a sense of uneasiness, distress, or dread), gastroesophageal reflux disease (GERD) (a chronic digestive disease where the liquid content of the stomach refluxes into the throat), and depression. Patient 3 was discharged on 08/30/22.

Review of Patient 3's "Patient Observation Rounds," showed that the following 15-minute safety checks were not completed:

08/19/22 - 5:45 AM, 10:45 AM, and 1:30 PM
08/21/22 - 6:00 AM
08/23/22 - 12:45 PM, 1:00 PM, 1:15 PM, 1:30 PM, and 1:45 PM
08/24/22 - 12:01 AM through 11:59 PM
08/26/22 - 5:45 AM and 11:45 AM
08/27/22 - 12:01 AM through 11:59 PM
08/30/22 - 5:45 AM


Patient 4

Review of Patient 4's discharged medical record showed that Patient 4 was voluntarily admitted on 08/18/22 after displaying suicidal ideation and increased difficulties of performing activities of daily living (ADLs). Patient 4 has the following diagnoses: anxiety disorder, bipolar disorder (a serious mental illness characterized by extreme mood swings), diabetes, insomnia, GERD, hyperlipidemia (high cholesterol), and hypertension. Patient 4 is suspected to have dementia. Patient 4 was discharged 08/30/22.

Review of Patient 4's "Patient Observation Rounds," showed that the following 15-minute safety checks were not completed:

08/18/22 - 4:40 PM and 7:00 PM
08/19/22 - 10:45 AM and 1:30 PM
08/22/22 - 2:05 AM and 6:45 AM
08/23/22 - 12:45 PM
08/24/22 - 2:45 AM


Patient 5

Review of Patient 5's current medical record showed that Patient 5 was involuntarily admitted on 08/19/22 after breaking into her chiropractor's office building. Patient 5 was admitted to her local hospital and increasingly became more physically and verbally abusive toward staff and refusing treatment. Patient 5 has the following diagnoses: unspecified dementia, mood disorder (general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function), and hypertension.

Review of Patient 5's "Patient Observation Rounds," showed that the following 15-minute safety checks were not completed:

08/19/22 - 5:45 AM
08/21/22 - 6:00 AM, 6:45 AM, and 7:06 AM
08/22/22 - 2:00 AM, 2:35 AM, 6:52 AM, and 11:45 AM
08/23/22 - 12:32 PM through 2:09 PM and 5:51 PM
08/26/22 - 5:45 AM, 9:45 AM and 11:45 AM
08/30/22 - 5:45 AM


During an interview on 08/30/22 at 7:40 PM, Staff G, Registered Nurse (RN), stated that Staff J, RN, Interim Clinical Director and Director of Nursing, informed her that it was okay if the patients were unaccompanied in the dayroom or hallway as long as the 15-minute safety checks were being done. Staff G stated that staff are just filling them in anyway and not actually laying their eyes on them.

During an interview on 09/01/22 at 2:52 PM, Staff A, Chief Executive Officer (CEO), Staff B, DRMQ, and Staff C, Chief Operations Officer (COO), were informed and acknowledged that the surveyors found safety concerns on the behavioral health unit and concerns regarding safety checks. Staff A stated that he purchased hospital beds specifically for the unit that minimize risk of harm to patients.

Based on policy review, record review, and interview the Hospital failed to ensure three of five patients reviewed (Patient 2, 4, and 5) were afforded their right to have visitors. This deficient practice has the potential to lead to harm and other adverse outcomes.


Findings Include:


Review of the Hospital's policy titled, "Visitors," dated 07/2022, showed, "It is the policy of the Behavioral Health program/unit that patients have the option to have visitors while on the unit."


Patient 2

Review of Patient 2's discharged medical record showed that Patient 2 was involuntarily admitted on 08/17/22 due to active psychosis and hallucinations that lead to calling the police repetitively and then not allowing the police to assist her or enter her room at the nursing home. Patient 2 has the following diagnoses: history of left temporal intracranial bleed (bleeding of the brain), morbid obesity, insomnia (difficulty falling and staying asleep), dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), depression, and hypertension (high blood pressure). Patient 2 was discharged on 08/30/22.

Review of Patient 2's "Visitation Consent" form showed that it was crossed out and it was written that the unit was closed to visitation due to COVID-19.


Patient 4

Review of Patient 4's discharged medical record showed that Patient 4 was voluntarily admitted on 08/18/22 after displaying suicidal ideation and increased difficulties of performing activities of daily living (ADLs). Patient 4 has the following diagnoses: anxiety disorder, bipolar disorder (a serious mental illness characterized by extreme mood swings), diabetes, insomnia, GERD, hyperlipidemia (high cholesterol), and hypertension. Patient 4 is suspected to have dementia. Patient 4 was discharged 08/30/22.

Review of Patient 4's medical record showed no evidence of a signed "Visitation Consent" form.


Patient 5

During an interview on 09/01/22 at 12:54 PM, family member (F) (F2), sister and Durable Power of Attorney (DPOA) for Patient 5, stated that she was informed that she was not allowed to visit Patient 5 while she was on the behavioral health unit. F2 stated that the unit was restricted due to COVID-19.


During an interview on 09/01/22 at 1:48 PM, Staff B, Director of Risk Management and Quality (DRMQ), stated that the current visitation being allowed as of 03/2022, due to COVID-19, were two visitors per patient and that no children were allowed. Staff B stated that as of this date, that all visitation restrictions have been lifted. Staff B stated that staff were notified of visitation changes through huddles and email. Staff B stated that it is her expectation that any restrictions placed on visitation are documented in the patient record.

Based on document review, policy review, record review, and interview, the Hospital failed ensure nursing staff followed hospital policy to conduct the "Columbia Suicide Severity Rating Scale (CSSRS) Lifetime/Recent Safe-T Protocol" upon admission for 4 of 5 patients (Patient 1, 2, 3, and 5) upon admission and failed to conduct the "CSSRS Daily/Frequent" assessment each shift for 5 of 5 patients reviewed (Patient 1, 2, 3, 4, and 5). This deficient practice has the potential to cause harm and other adverse outcomes, including death.

Findings Include:

Review of the Hospital's policy, "Suicide Assessment and Prevention," dated 07/2022, showed, "The unit will use the Columbia Suicide Severity Rating Scale Lifetime/Recent SAFE-T Protocol on admission on every patient. The Columbia Suicide Severity Rating Scale Daily/Frequent will be used each shift on every patient." Further review showed, "It is recommended that within 2 [two] hours of a patient being admitted to the unit, the admitting RN should complete the Suicide Risk Assessment . . . re-assessment of suicide risk by the RN will occur on every shift for all patients."


Patient 1

Review of Patient 1's current medical record showed that Patient 1 was voluntarily admitted on 08/17/22 after attempting a suicide by overdosing on oxycodone (a medication used to treat pain). Patient 1 has the following diagnoses: fibromyalgia (disorder that affects muscle and soft tissue characterized by chronic pain that causes tenderness, fatigue, and sleep disturbances), angina (chest discomfort or shortness of breath when heart muscles receive insufficient oxygen-rich blood), diabetes (high blood sugar levels for extended periods of time), hypothyroid (decrease in production of thyroid hormones), deep vein thrombosis (DVT) (clotting deep inside the veins, usually the thighs and lower legs), and depression (persistent sadness and lack of interest or pleasure in once enjoyable activities).

Review of Patient 1's "CSSRS Lifetime/Recent" assessment showed that the assessment was incomplete. The assessment appears to have been completed by Patient 1 as evidenced by Patient 1's name is printed on the spot indicated for "Signature of Assessor." The form is not signed by hospital staff.

Review of Patient 1's medical record showed no evidence of a "CSSRS Daily/Frequent," assessments being completed for Patient 1. Further review showed that no "CSSRS Daily/Frequent," assessments were scanned to Patient 1's medical record.


Patient 2

Review of Patient 2's discharged medical record showed that Patient 2 was involuntarily admitted on 08/17/22 due to active psychosis and hallucinations that lead to calling the police repetitively and then not allowing the police to assist her or enter her room at the nursing home. Patient 2 has the following diagnoses: history of left temporal intracranial bleed (bleeding of the brain), morbid obesity, insomnia (difficulty falling and staying asleep), dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), depression, and hypertension (high blood pressure). Patient 2 was discharged on 08/30/22.

Review of Patient 2's "CSSRS Lifetime/Recent" assessment showed that it was completed on 08/17/22 at 2:15 AM by Staff O, Registered Nurse (RN). Further review shows that the assessment was not fully completed and does not indicate a risk level for Patient 2.

Review of Patient 2's medical record showed no evidence of a "CSSRS Daily/Frequent," assessments being completed for Patient 2. Further review showed that no "CSSRS Daily/Frequent," assessments were scanned to Patient 2's medical record.


Patient 3

Review of Patient 3's discharged medical record showed that Patient 3 was admitted after being found wandering in a corn field and after interactions with law enforcement due to bizarre behavior. Patient 3 has the following diagnoses: Parkinson's Disease (a chronic and progressive movement disorder that initially causes tremor, stiffness, or slowing of movement), Schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thought and behaviors), insomnia, anxiety (the mind and body's response to stressful, dangerous, or unfamiliar situations, that leave a sense of uneasiness, distress, or dread), gastroesophageal reflux disease (GERD) (a chronic digestive disease where the liquid content of the stomach refluxes into the throat), and depression. Patient 3 was discharged on 08/30/22.

Review of Patient 3's "CSSRS Lifetime/Recent" assessment showed that the assessment was incomplete, does not include a risk level for Patient 3, and does not include the assessors signature or the date and time of completion.

Review of Patient 3's medical record showed no evidence of a "CSSRS Daily/Frequent," assessments being completed for Patient 3. Further review showed that no "CSSRS Daily/Frequent," assessments were scanned to Patient 3's medical record.


Patient 4

Review of Patient 4's discharged medical record showed that Patient 4 was voluntarily admitted on 08/18/22 after displaying suicidal ideation and increased difficulties of performing activities of daily living (ADLs). Patient 4 has the following diagnoses: anxiety disorder, bipolar disorder (a serious mental illness characterized by extreme mood swings), diabetes, insomnia, GERD, hyperlipidemia (high cholesterol), and hypertension. Patient 4 is suspected to have dementia. Patient 4 was discharged 08/30/22.

Review of Patient 4's medical record showed no evidence of a "CSSRS Daily/Frequent," assessments being completed for Patient 4. Further review showed that no "CSSRS Daily/Frequent," assessments were scanned to Patient 4's medical record.


Patient 5

Review of Patient 5's current medical record showed that Patient 5 was involuntarily admitted on 08/19/22 after breaking into her chiropractor's office building. Patient 5 was admitted to her local hospital and increasingly became more physically and verbally abusive toward staff and refusing treatment. Patient 5 has the following diagnoses: unspecified dementia, mood disorder (general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function), and hypertension.

Review of Patient 5's "CSSRS Lifetime/Recent" assessment showed that an incomplete and blank form, unsigned by staff, was scanned to Patient 5's record.

Review of Patient 5's medical record showed no evidence of a "CSSRS Daily/Frequent," assessments being completed for Patient 5. Further review showed that no "CSSRS Daily/Frequent," assessments were scanned to Patient 5's medical record.

Based on record review, policy review, and interview, the Hospital failed to ensure medications were administer as ordered for 3 of 5 patients reviewed (Patient 2, 3, and 4). These deficient practices has the potential to cause medical and psychiatric diagnoses to go untreated, other adverse outcomes, or death.


Findings Include:


Review of the Hospital's policy titled, "Administration of Medications and Medication Verification," last reviewed 08/2021, showed "The nurse will verify new medications, and/or medication changes prior to administering medications. Medications will be administered to the patient using the Med-Verify component of the electronic MAR (Medication Administration Record). The nurse will scan the patient's armband at the bedside. The medication will be scanned at the bedside. The medication will be administered to the patient after the Med-Verify process has been completed . . . The nurse must verify that the five rights of Medication Administration are met."



Patient 2

Review of Patient 2's discharged medical record showed that Patient 2 was involuntarily admitted on 08/17/22 due to active psychosis and hallucinations that lead to calling the police repetitively and then not allowing the police to assist her or enter her room at the nursing home. Patient 2 has the following diagnoses: history of left temporal intracranial bleed (bleeding of the brain), morbid obesity, insomnia (difficulty falling and staying asleep), dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), depression, and hypertension (high blood pressure). Patient 2 was discharged on 08/30/22.

Review of Patient 2's medications orders showed an order for Zyprexa (medication used to treat severe agitation associated with certain mental/mood conditions) 5 mg, by mouth, twice daily.

Review of Patient 2's medication administration record (MAR) showed Patient 2 was not administered Zyprexa on the following dates and times:

08/22/22 at 5:00 PM
08/23/22 at 6:00 AM and 5:00 PM


Patient 3

Review of Patient 3's discharged medical record showed that Patient 3 was admitted after being found wandering in a corn field and after interactions with law enforcement due to bizarre behavior. Patient 3 has the following diagnoses: Parkinson's Disease (a chronic and progressive movement disorder that initially causes tremor, stiffness, or slowing of movement), Schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thought and behaviors), insomnia, anxiety (the mind and body's response to stressful, dangerous, or unfamiliar situations, that leave a sense of uneasiness, distress, or dread), gastroesophageal reflux disease (GERD) (a chronic digestive disease where the liquid content of the stomach refluxes into the throat), and depression. Patient 3 was discharged on 08/30/22.

Review of Patient 3's medication orders showed that Patient 3 had the following medication orders:

Buspar (medication used to treat anxiety) 10 mg, three times daily
Latanoprost 0.005% OPHT solution (medication used to treat high blood pressure inside the eye due to eye disease), 1 drop both eyes, daily
Glucophage (medication used to treat diabetes) 500 mg, twice daily with meals
Buspar 15 mg, three times daily (changed on 08/28/22 at 6:53 PM)

Review of Patient 3's MAR showed the following medications were not administered:

08/17/22 at 8:26 PM Latanoprost 0.0005% OPHT solution, med not available
08/18/22 at 8:42 PM Latanoprost 0.0005% OPHT solution, med not available
08/19/22 at 9:00 PM Latanoprost 0.0005% OPHT solution, med not available
08/20/22 at 9:17 PM Latanoprost 0.0005% OPHT solution, med not available
08/21/22 at 7:48 PM Latanoprost 0.0005% OPHT solution, med not available
08/22/22 at 10:22 PM Latanoprost 0.0005% OPHT solution, med not available
08/23/22 at 11:00 AM Buspar 10 mg
08/23/22 at 8:27 PM Latanoprost 0.0005% OPHT solution, med not available
08/29/22 at 5:00 PM Glucophage 500 mg
08/29/22 at 5:00 PM Buspar 15 mg


Patient 4

Review of Patient 4's discharged medical record showed that Patient 4 was voluntarily admitted on 08/18/22 after displaying suicidal ideation and increased difficulties of performing activities of daily living (ADLs). Patient 4 has the following diagnoses: anxiety disorder, bipolar disorder (a serious mental illness characterized by extreme mood swings), diabetes, insomnia, GERD, hyperlipidemia (high cholesterol), and hypertension. Patient 4 is suspected to have dementia. Patient 4 was discharged 08/30/22.

Review of Patient 4's medical record showed an allergy to acetaminophen (medication used to treat pain or fever).

Patient 4 was administered acetaminophen on 08/20/22 at 2:21 PM and 08/21/22 at 4:32 PM.

Review of Patient 4's medication orders showed the following orders:

Nystatin Suspension (medication used to treat thrush, a yeast infection of the mouth) 5 mL (milliliters), four times daily
Lidocaine 20% oral solution (medication used for numbing) 10 mL, with meals
Buspirone 5 mg, three times daily with meals

Review of Patient 4's MAR showed the following the following medications were not administered:

08/24/22 at 7:45 AM, 12:40 PM, and 8:06 PM Nystatin Suspension 5 mL
08/24/22 at 11:33 PM Lidocaine 20 % oral solution 10 mL
08/25/22 at 7:30 AM Lidocaine 20 % oral solution 10 mL, med documented as not available
08/26/22 at 7:00 AM, 1:40 PM, and 5:24 PM Nystatin Suspension 5 mL
08/29/22 at 6:59 AM and 11:21 AM Lidocaine 20 % oral solution 10 mL
08/28/22 at 6:59 AM and 11:21 AM Buspirone 5 mg

Review of Patient 4's "Nurse Note," dated 08/30/22 at 5:25 AM, Staff S, Registered Nurse (RN) documented, "At HS (bedtime), pt (patient) requests med for anxiety, states he is stressing about going home tomorrow. PRN Atarax (medication used to treat itching and allergies) given per orders. Pt slept through the night." Review of the MAR showed that the medication was not documented.


During an interview on 09/01/22 at 2:52 PM, Staff A, Chief Executive Officer (CEO), Staff B, Director of Risk Management and Quality (DRMQ), and Staff C, Chief Operations Officer (COO), were informed and acknowledged that the surveyors found medication errors in the charts reviewed.

Based on policy review, medical record review, and interview the Hospital failed to use verbal orders limited to situations where immediate written or electronic communications were not feasible according to their policy and procedure affecting 2 of 5 patients reviewed (Patient 3 and 5). This deficient practice has the potential to lead to confusion, errors, unauthenticated orders, and other adverse outcomes.


Findings Include:


Review of the Hospital's policy titled, "Verbal & Telephone Orders," dated 07/2022, showed, "It is the policy of [above-named Hospital] that the use of verbal & telephone orders is discouraged. Verbal & telephone orders shall be processed in accordance with medical staff rules and regulations and hospital policy. Please note that verbal orders are limited to situations where immediate written or electronic communication is not feasible."


Patient 3

Review of Patient 3's discharged medical record showed that Patient 3 was admitted after being found wandering in a corn field and after interactions with law enforcement due to bizarre behavior. Patient 3 has the following diagnoses: Parkinson's Disease (a chronic and progressive movement disorder that initially causes tremor, stiffness, or slowing of movement), Schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thought and behaviors), insomnia, anxiety (the mind and body's response to stressful, dangerous, or unfamiliar situations, that leave a sense of uneasiness, distress, or dread), gastroesophageal reflux disease (GERD) (a chronic digestive disease where the liquid content of the stomach refluxes into the throat), and depression. Patient 3 was discharged on 08/30/22.

Review of Patient 3's physician orders showed 28% of the orders were verbal orders:

08/18/22 at 7:59 AM Admission orders that includes: Admit, Diagnosis, Allergies, Medical Consult, May crush meds, Dietary consult, daily weights, Group therapy, recreational therapy, individual therapy, physical therapy if indicated, continue all home medications, enhance sleep orders, Hold BP (blood pressure) if SBP <110 call MD, if SBP >140 after holding meds, vital signs every shift, please complete MMSE/SLUMS
08/18/22 at 7:59 AM comprehensive metabolic profile (a blood test that evaluates liver function, kidney function, and nutrient levels)
08/18/22 at 7:59 AM Urinalysis Culture (a urine test used to determine bacterial growth)
08/18/22 at 7:59 AM Vitamin B12 (a lab test that measures the body's Vitamin B level)
08/18/22 at 7:59 AM folic acid serum (a lab test that measures the body's folic acid level)
08/18/22 at 7:59 AM TSH (thyroid stimulating hormone) (a blood test to evaluate the thyroid stimulating hormone)
08/18/22 at 7:59 AM CBC (complete blood count) with differential (a blood test that looks at the production of blood, oxygen carrying capacity, and provides information about the immune system and determine if illness is present)
08/18/22 at 7:59 AM CBC (complete blood count) with differential (a blood test that looks at the production of blood, oxygen carrying capacity, and provides information about the immune system and determine if illness is present)
08/18/22 at 8:00 AM diabetic diet
08/18/22 at 8:00 AM metabolic basic profile
08/18/22 at 8:00 AM lipid profile (a blood test that checks the cholesterol level and triglycerides in the blood)
08/18/22 at 8:00 AM hemoglobin A1C3 (a blood test that measures the average blood glucose over a three month period)
08/24/22 at 12:21 PM medical consult related to blood pressure and cough
08/24/22 at 9:26 AM Ensure (supplemental drink) 8-ounce liquid
08/25/22 at 8:10 PM EKG (electrocardiogram) (a test that measures electrical activity of the heart to detect cardiac problems)
08/28/22 at 6:56 PM haloperidol (medication used to treat certain mental/mood disorders) 5 mg, as needed every six hours
08/28/22 at 6:56 PM buspirone (medication used to treat anxiety) 15 mg, three times daily with meals
08/29/22 at 8:05 PM discharge home


Patient 5

Review of Patient 5's current medical record showed that Patient 5 was involuntarily admitted on 08/19/22 after breaking into her chiropractor's office building. Patient 5 was admitted to her local hospital and increasingly became more physically and verbally abusive toward staff and refusing treatment. Patient 5 has the following diagnoses: unspecified dementia, mood disorder (general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function), and hypertension.

Review of Patient 5's physician orders showed 25% of the orders were verbal orders:

08/18/22 at 11:15 PM magnesium/aluminum/simethicone (medication to treat stomach upset, heartburn, and acid indigestion) 30 mL suspension, PRN (as needed) every six hours
08/18/22 at 11:24 PM Ibuprofen (medication used to treat pain or fever) 200 mg, 400 mgs PRN every six hours
08/18/22 at 11:24 PM trazodone (medication used to treat insomnia) 50 mg, PRN at bedtime
08/18/22 at 11:24 PM ondansetron ODT (medication used to treat nausea) 4 mg, PRN every six hours
08/18/22 at 11:24 PM lorazepam (medication used to treat anxiety) 1 mg PRN every six hours
08/18/22 at 11:25 PM Haloperidol 5 mg, by mouth or intramuscular (IM), PRN every six hours
08/23/22 at 5:17 AM haloperidol vial 5 mg/mL, PRN every six hours
08/23/22 at 5:17 AM haloperidol vial 5 mg/ mL, PRN three times daily
08/23/22 at 5:27 AM haloperidol vial 5 mg/mL, once
08/23/22 at 9:21 AM lorazepam vial 2 mg/1 mL, 10 mL, once
08/23/22 at 5:33 PM haloperidol 2 mg tab, PRN every six hours
08/23/22 at 5:33 PM lorazepam 0.5 mg tab, PRN every eight hours


During an interview on 09/01/22 at 9:17 AM, Staff D, Vice President of contracted behavioral health unit, stated that both doctors (Staff E, Medical Doctor (MD) and F, Doctor of Nursing Practice (DNP)) have the capability of going into the electronic medical record and submit their own orders.

During an interview on 09/01/22 at 10:49 AM, Staff E, MD, stated that verbal orders are used for new admissions, STAT (immediate) orders, and other reasons out of nowhere.

Based on record review and interview, the Hospital failed to ensure that all medication errors were immediately reported to the attending physician or their Quality Assessment and Performance Improvement Program (QAPI) for 5 of 5 patients reviewed (Patient 1, 2, 3, 4, and 5). This deficient practice has the potential for medication errors to remain unreported and uninvestigated, prevents interventions provided by the physician, and may lead to harm and other adverse outcomes, including death.

Findings Include:

Review of the Hospital's policy titled, "Administration of Medications and Medication Verification," last reviewed 08/2021, showed that it lacked information and instruction on how to handle medication variances, errors, the requirement to contact the physician, and documentation to occur in the patient's chart.


Patient 1

Review of Patient 1's current medical record showed that Patient 1 was voluntarily admitted on 08/17/22 after attempting a suicide by overdosing on oxycodone (a medication used to treat pain). Patient 1 has the following diagnoses: fibromyalgia (disorder that affects muscle and soft tissue characterized by chronic pain that causes tenderness, fatigue, and sleep disturbances), angina (chest discomfort or shortness of breath when heart muscles receive insufficient oxygen-rich blood), diabetes (high blood sugar levels for extended periods of time), hypothyroid (decrease in production of thyroid hormones), deep vein thrombosis (DVT) (clotting deep inside the veins, usually the thighs and lower legs), and depression (persistent sadness and lack of interest or pleasure in once enjoyable activities).

Review of Patient 1's "Emergency Physician Record," dated 08/17/22 at 8:30 PM showed past history included hypertension and DVTs.

Review of Patient 1's form "Medication Brought in by the Patient," showed the following medications:

Gabapentin (a medication used to prevent and control seizures or can be used to relieve nerve pain) 100 mg (milligrams)
Metoprolol (medication used to treat chest pain, heart failure, and high blood pressure) 50 mg
Bupropion (medication used to treat depression) 150 mg
Duloxetine (medication used to treat depression and anxiety) 30 mg
Armour thyroid (medication used to treat underactive thyroid) 90 mg,
Lisinopril (medication used to treat high blood pressure) 20 mg
Xarelto (medication used to prevent and treat blood clots) 10 mg."

Review of Patient 1's "History and Physical" completed on 08/17/22 showed "chart review, consultation with on-duty staff member completed. Medications, labs/diagnostics, and vital signs reviewed . . . Past medical history: hypertension, diabetes, hypothyroidism, fibromyalgia, chronic pain." Further review showed, "Home Meds: dose and Frequency:

Duloxetine Hydrochloride (HCl) 30 mg daily
Gabapentin 100 mg two times daily
Lisinopril 20 mg daily
Metoprolol tartrate 75 mg daily
Bupropion HCl 150 mg daily
Acetaminophen PM 500 mg/25 mg two caps every six hours

The H&P failed to include Xarelto.

Review of Patient 1's medications from the History and Physical showed the following orders:

Trazodone (used to treat depression) 50 mg, as needed (PRN) at bedtime
NF-Armour Thyroid 90 mg, daily
Duloxetine DR (delayed release) 30 mg, daily
Gabapentin 100 mg, twice daily
Lisinopril 20 mg, daily
Metoprolol 75 mg, twice daily
Quetiapine 25 mg, twice daily
Tramadol (used to treat pain) 50 mg, PRN every eight hours
Oxycodone (used to treat pain) 5 mg, twice daily

There was no documented evidence to show whether Patient 1 was to continue or discontinue Xarelto to treat and prevent the patient from DVTs.

Review of the patient record showed no documented evidence that the error was noted during chart checks or that the error was reported to the physician or QAPI for interventions or investigation.



Patient 2

Review of Patient 2's discharged medical record showed that Patient 2 was involuntarily admitted on 08/17/22 due to active psychosis and hallucinations that lead to calling the police repetitively and then not allowing the police to assist her or enter her room at the nursing home. Patient 2 has the following diagnoses: history of left temporal intracranial bleed (bleeding of the brain), morbid obesity, insomnia (difficulty falling and staying asleep), dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), depression, and hypertension (high blood pressure). Patient 2 was discharged on 08/30/22.

Review of Patient 2's medications orders showed an order for Zyprexa (medication used to treat severe agitation associated with certain mental/mood conditions) 5 mg, by mouth, twice daily.

Review of Patient 2's medication administration record (MAR) showed Patient 2 did not receive Zyprexa as ordered on the following dates and times:

08/22/22 at 5:00 PM
08/23/22 at 6:00 AM and 5:00 PM

Review of the patient record showed no documented evidence that the errors were noted during chart checks or that the errors were reported to the physician or QAPI for interventions or investigation.


Patient 3

Review of Patient 3's discharged medical record showed that Patient 3 was admitted after being found wandering in a corn field and after interactions with law enforcement due to bizarre behavior. Patient 3 has the following diagnoses: Parkinson's Disease (a chronic and progressive movement disorder that initially causes tremor, stiffness, or slowing of movement), Schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thought and behaviors), insomnia, anxiety (the mind and body's response to stressful, dangerous, or unfamiliar situations, that leave a sense of uneasiness, distress, or dread), gastroesophageal reflux disease (GERD) (a chronic digestive disease where the liquid content of the stomach refluxes into the throat), and depression. Patient 3 was discharged on 08/30/22.

Review of Patient 3's medication orders showed that Patient 3 had the following medication orders:

Buspar (medication used to treat anxiety) 10 mg, three times daily
Latanoprost 0.005% OPHT solution (medication used to treat high blood pressure inside the eye due to eye disease), 1 drop both eyes, daily
Glucophage (medication used to treat diabetes) 500 mg, twice daily with meals
Buspar 15 mg, three times daily (changed on 08/28/22 at 6:53 PM)

Review of Patient 3's MAR showed the following medications were not administered:

08/17/22 at 8:26 PM Latanoprost 0.0005% OPHT solution, med not available
08/18/22 at 8:42 PM Latanoprost 0.0005% OPHT solution, med not available
08/19/22 at 9:00 PM Latanoprost 0.0005% OPHT solution, med not available
08/20/22 at 9:17 PM Latanoprost 0.0005% OPHT solution, med not available
08/21/22 at 7:48 PM Latanoprost 0.0005% OPHT solution, med not available
08/22/22 at 10:22 PM Latanoprost 0.0005% OPHT solution, med not available
08/23/22 at 11:00 AM Buspar 10 mg
08/23/22 at 8:27 PM Latanoprost 0.0005% OPHT solution, med not available
08/29/22 at 5:00 PM Glucophage 500 mg
08/29/22 at 5:00 PM Buspar 15 mg

Review of the patient record showed no documented evidence that the errors were noted during chart checks or that the errors were reported to the physician or QAPI for interventions or investigation.


Patient 4

Review of Patient 4's discharged medical record showed that Patient 4 was voluntarily admitted on 08/18/22 after displaying suicidal ideation and increased difficulties of performing activities of daily living (ADLs). Patient 4 has the following diagnoses: anxiety disorder, bipolar disorder (a serious mental illness characterized by extreme mood swings), diabetes, insomnia, GERD, hyperlipidemia (high cholesterol), and hypertension. Patient 4 is suspected to have dementia. Patient 4 was discharged 08/30/22.

Review of Patient 4's medical record showed an allergy to acetaminophen (medication used to treat pain or fever). Patient 4 was administered acetaminophen on 08/20/22 at 2:21 PM and 08/21/22 at 4:32 PM.

Review of Patient 4's medication orders showed the following orders:

Nystatin Suspension (medication used to treat thrush, a yeast infection of the mouth) 5 mL (milliliters), four times daily
Lidocaine 20% oral solution (medication used for numbing) 10 mL, with meals
Buspirone 5 mg, three times daily with meals

Review of Patient 4's MAR showed the following the following medications were not administered:

08/24/22 at 7:45 AM, 12:40 PM, and 8:06 PM Nystatin Suspension 5 mL
08/24/22 at 11:33 PM Lidocaine 20 % oral solution 10 mL
08/25/22 at 7:30 AM Lidocaine 20 % oral solution 10 mL, med documented as not available
08/26/22 at 7:00 AM, 1:40 PM, and 5:24 PM Nystatin Suspension 5 mL
08/29/22 at 6:59 AM and 11:21 AM Lidocaine 20 % oral solution 10 mL
08/28/22 at 6:59 AM and 11:21 AM Buspirone 5 mg

Review of Patient 4's "Nurse Note," dated 08/30/22 at 5:25 AM, Staff S, Registered Nurse (RN) documented, "At HS (bedtime), pt (patient) requests med for anxiety, states he is stressing about going home tomorrow. PRN Atarax (medication used to treat itching and allergies) given per orders. Pt slept through the night."

Review of the MAR showed Atarax was not documented.

Review of the patient record showed no documented evidence that the errors were noted during chart checks or that the errors were reported to the physician or QAPI for interventions or investigation.

During an interview on 09/01/22 at 10:49 AM, Staff E, Medical Doctor (MD), stated that he would expect nursing staff to notify him as soon as possible about medication errors.

During an interview on 09/01/22 at 12:26 PM, Staff F, Doctor of Nursing Practice (DNP), stated that she would expect staff to notify her of any medication errors so that any issues can be addressed.

During an interview on 09/01/22 at 1:48 PM, Staff B, Director of Risk Management and Quality (DRMQ), stated that all medication errors should be reported through the quality data checks and in turn, reported to her. Staff B stated that she then would follow up with pharmacy to ensure that the physician was contacted.

During an interview on 09/01/22 at 2:52 PM, Staff A, Chief Executive Officer (CEO), Staff B, DRMQ, and Staff C, Chief Operations Officer (COO), were informed and acknowledged that the surveyors found medication errors in the record reviewed.