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Based upon observation, record review and interview, the governing body failed to;

A.) ensure the physician on call was available to staff to respond to patient needs in 1 (patient #1) of 5 (patients #1, #6, #8, #17 #18) records reviewed.

Refer to Tag A0067


B.) have a mechanism to evaluate the quality of each contracted service, secure employee confidential information for contracted staff, and enforce the contracted services obligation to provide the facility with satisfactory documentation of current liability insurance.
Refer to Tag A0084

C.) ensure that an ongoing program for quality improvement and patient safety (falls), including the reduction of medical and medication errors, is defined, implemented, and maintained.

Refer to Tag A0309



D.) ensure the patients and patient representatives were provided information about the patients health status, diagnosis, and prognosis. To ensure the patient was mentally capable of understanding consent for treatment, given their bill of rights, and correctly identifying a Legally Authorized Representative in 3 (#3, 5, and 7) of 5 (#3, 5, 7, 8,18) charts reviewed.

Refer to Tag A0117

E.) follow their own policy and respond to a grievance in a timely manner in 1 (patient #14) of 2 (patients #4 and #14) grievances reviewed.

Refer to Tag A0122

F.) ensure 13 of 13 (#1-#13) in-patients the right to considerate and respectful care during meal service.

Refer to Tag A0129

G.) ensure the patients and patient representatives were provided information about the patients health status, diagnosis, and prognosis. To ensure the patient was mentally capable of understanding consent for treatment, given their bill of rights, and correctly identifying a Legally Authorized Representative in 3(#3, 5, and 7) of 5 (#3, 5, 7, 8,18) charts reviewed.

Refer to Tag A0131

H.) ensure the patients were safe from falls, report out of range blood pressures and critical glucose values, document safety measures while sleeping in day area and at nurses station, and implement nursing interventions to prevent falls in 2 (#3 and 16) out of 5 (#2, 3, 7, 8, and 16) patients reviewed. The facility failed to follow their own policy requiring staff to visually observe patients every 15 minutes for location, activity, behavior and unsafe activities in 3 (patients #1, #6 and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.

Refer to Tag A0141, A0144
I.) provide laboratory services in a safe setting. The contracted laboratory provider failed to follow facility policies and failed to demonstrate safe standards of infection control,when providing venipuncture for blood specimen collection, for 6 of 13 patients. The nursing staff failed to sanitize the dining room tables after venipuncture had been conducted, or prior to the breakfast meal being served for 13 of 13 patients.
Refer to Tag A0144, A0576, A0747

J.) have a tracking system for death in restraints.

Refer to Tag A0214




K.) properly assess patients with elevated blood pressures and blood sugars, nursing interventions, and document notification of critical lab values in 3(#3, 7, and 16) of 5(#3, 7, 8, 16 and 17) patients reviewed. The facility failed to ensure all patients received a complete nursing physical and psychological assessment every 12 hours in 2 (patients #8 and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.


Refer to Tag A0144, A0395


L.) ensure orders taken by nursing staff from physicians were reviewed and signed by the ordering physician promptly following order initiation in 3 (patients #1, #6 and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.

Refer to Tag A0454


M.) ensure their Utilization Plan provided for review of services furnished by the facility and by members of the facility's medical staff.

Refer to Tag A0654

Based on record review and interview the facility failed to ensure the physician on call was available to staff to respond to patient needs in 1 (patient #1) of 5 (patients #1, #6, #8, #17, #18) records reviewed.
Review of patient #1's record revealed a "Multi-Disciplinary Note" with documentation of an incident on 12/11/2015, when patient #1 became agitated and struck a staff member. The following documentation indicated the physician did not respond to staff's calls and text messages requesting physician's assistance for 4 hours and 20 minutes. "...12/11 (2015) 1430 (2:30 p.m.) Attempted to contact staff #12 for PO order no answer. Staff #12 texted awaiting R/C (return call) ....12-11 (2015) 1700 NSG (nursing) #1 Still no answer from Staff #12. Patient still agitated and aggressive. Staff #35 (signature) .... 12/11 (2015) 1850 (6:50 p.m.) NSG #1 Staff #12 call due to pt (patient) still aggressive and agitated. Staff #12 orders Zyprexa 10 mg PO 1 times."
An interview with staff #1 confirmed the facility had an issue with on call physicians response times.

Based on document review and interview, the facility failed to have a mechanism to evaluate the quality of each contracted service, secure employee confidential information for contracted staff and enforce the contracted services obligation to provide the facility with satisfactory documentation of current liability insurance.

Review of the contracted services revealed they were kept in two large black binders on a book shelf in the administrator's office. Inside the binders were contracts for Dieticians, Physical Therapist, and Occupational Therapist. The contracts had employee files attached with the personal information of the contractor such as social security numbers, salaries, bank account information, and W4's.

Review of the Quality Assessment and Performance Improvement (QAPI) plan for 2015 revealed no evidence that every contracted service was evaluated or followed in the QAPI plan.

An interview with the Administrator on 12/15/15 at 11:35 AM confirmed that she had not looked at the contracted services and was not aware that employee files were included in the contract book or if any contracts had expired.

An interview with staff #6 (HR) on 12/15/15 confirmed she was aware the contract book had vendor's sensitive personal information in them instead of the HR office where that information is secured. Staff #6 stated, "The last administrator insisted on keeping it like that in her office."

An interview with the staff #3 (QAPI) on 12/16/15 at 11:15 AM reported that contracts are discussed in the QAPI but there was no evidence presented from meetings to determine there is a mechanism to evaluate the quality of each contracted service. Staff #3 reported she was unaware if there were any expired contracts. Staff #3 reported the administrators had always kept up with the contracts. Staff #3 confirmed she had no knowledge of the contracted services or how they were evaluated.











35515

Review of the facility's contracts revealed a contract with the nurse staffing agency for staffing services of licensed and unlicensed personnel dated May 7, 2014. Further review of the contract revealed the following statement, "Insurance Contractor shall maintain for itself and on behalf of each of its personnel providing services hereunder general liability and professional liability and workers compensation insurance. Contractor shall supply Hospital with satisfactory documentation of such insurance to Hospital. Hospital will be given at least thirty (30) days notice prior to the cancellation of any such policies."

Review of the facility's file for the nurse staffing agency revealed a form titled "Certificate of Liability Insurance" dated "1/28/2014", and issued to the nurse staffing agency. The insurance form stated the expiration date for "general liability, umbrella liability and professional liability" was listed as "12/1/2014". The "workers compensation and employers' liability" expiration date was listed as "5/27/2014".


Review of the Governing Body bylaws under, Contracted Services, stated "the Governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The Governing Body must ensure that the contractor of services furnishes services that permit the hospital to comply with all applicable conditions of participation and standards of the contracted services."


Review of the nurse staffing agency employee time sheets for the facility revealed the facility was currently utilizing the services of the contracted nurse staffing agency. The time sheets reflected that 2 of the nurse staffing agency's licensed employees worked at the facility for a total of 97.5 hours in November 2015 and 13.75 hours in December 2015.

It was concluded that the facility did not enforce the nurse staffing agency's contracted obligation to provide the facility with satisfactory documentation of current liability insurance.

An interview with the Administrator on 12/15/15 at 11:35 AM confirmed that she had not looked at the contracted services files and was unaware of any contracts or liability insurance of contractors that had expired.

Based upon observation, record review and interview, the facility failed to:
A.) ensure the patients and patient representatives were provided information about the patients health status, diagnosis, and prognosis. To ensure the patient was mentally capable of understanding consent for treatment, given their bill of rights, and correctly identifying a Legally Authorized Representative in 3 (#3, 5, and 7) of 5 (#3, 5, 7, 8, 16) charts reviewed.

Refer to Tag A0117

B.) follow their own policy and respond to a grievance in a timely manner in 1 (patient #14) of 2 (patients #4 and #14) grievances reviewed.

Refer to Tag A0122

C.) ensure 13 of 13 (#1-#13) in-patients the right to considerate and respectful care during meal service.

Refer to Tag A0129

D.) ensure the patients and patient representatives were provided information about the patients health status, diagnosis, and prognosis. To ensure the patient was mentally capable of understanding consent for treatment, given their bill of rights, and correctly identifying a Legally Authorized Representative in 3(#3, 5, and 7) of 5 (#3, 5, 7, 8, 16) charts reviewed.

Refer to Tag A0131

E.) ensure the patients were safe from falls, report out of range blood pressures and critical glucose values, document safety measures while sleeping in day area and at nurses station, and implement nursing interventions to prevent falls in 2 (#3 and 16) out of 5 (#2, 3, 7, 8, and 16) patients reviewed. The facility failed to follow their own policy requiring staff to visually observe patients every 15 minutes for location, activity, behavior and unsafe activities in 3 (patients #1, #6 and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.

Refer to Tag A0141

F.) have a tracking system for death in restraints.

Refer to Tag A0214

Based on chart reviews and interviews, the facility failed to ensure the patients and patient representatives were provided information about the patients health status, diagnosis, and prognosis. To ensure the patient was mentally capable of understanding consent for treatment, given their bill of rights, and correctly identifying a Legally Authorized Representative in 3 (#3, 5, and 7) of 5 (#3, 5, 7, 8, 16) charts reviewed.

1.) Review of the Request for Voluntary Admission dated 12/8/15 at 7:00AM revealed the patient #7 signed the form but there was no witness signature date or time.

Review of the Patient Bill of Rights form revealed patient #7 signed the form on 12/8/15. However, the bottom of the form has the following questions that require a check if completed. All of the questions were blank;

I certify that:
I have received a copy of this four-page document prior to admission.
Staff have explained to me in a language I understand within 24 hours of admission (if involuntarily committed).
Staff have explained its contents to me in a language I understand prior to admission (if voluntarily committed). There was no evidence found that patient #7 was given her bill of rights.

2.) Review of patient #3's chart revealed the patient was admitted to the facility on 12-4-15 at 5:15PM. Patient #3 was admitted with a diagnosis of Neurocognitive Disorder with Behavioral Disturbances, involuntarily on an Emergency Police Officers Warrant (EPOW). Patient #3 has had a negative psychiatric history. No psychotropic medications have ever been taken by patient #3.

Review of Consent for Treatment and the Patient Bill of Rights revealed they were blank. On the back of the consent a statement was written. The statement stated, "12/4/15 at 5:07PM Patient unable to sign in current condition. Uncontrollable crying."

Review of the Daily Multidisciplinary Note dated 12/5/15 at 5:46PM revealed staff #30 met with patient #3 to finish her psych/social information. Staff #30 reported the patient was tearful and unable to give information to complete the assessment. The patients' granddaughter was called to gather the information needed. Staff #30 stated, "social worker discussed the patient's rights, confidentiality and the grievance process with the patient. Patient verbalized an understanding of all above." Review of the Nurses notes for 12/5/15 revealed the patient was confused.

Review of the Psychiatric Evaluation on 12/6/15 revealed patient #3 was notably labile with long periods of uncontrollable crying contrasted by long periods of bizarre laughter. Patient #3 had disorganized behavior and laughed inappropriately. Her reasoning is illogical and had loose associations.

There was no further evidence that patient #3 was given her bill of rights or had any conversation with staff regarding her EPOW status or the application of an Order of Protective Custody (OPC).

Review of patient #3's Informed Consent for Psychotropic Medication revealed the patient did not sign consents. The following statement was written on the patient signature line, "Verbal consent received from the LAR-(granddaughter's name). "There was no found evidence that Patient #3 had a Legally Authorized Representative (LAR).

3.) Review of patient #5's chart revealed the patient was at a nursing home and was having some behavioral issues, confusion and sexually inappropriate. Review of the Request for Voluntary Admission form revealed on the patient signature line a squiggly line as the patient signature. On the back of the form staff #36 documented, "11/30/15 at 6:02PM I, staff #36 met with patient #5 on unit at patient #5's nursing home. Patient #5 was able to tell me his name that he was at the nursing home. I talked to him about placement at the facility. He states he is willing to admit to the facility for an inpatient placement and he voluntarily signed this paper for in-patient placement."

Review of the admission forms Patient Rights, Hospital care Consent, Grievance Processes, were all blank. On the back of the forms was a statement from the RN, "12/1/15 4:30PM Pt unable to sign related to drowsy unable to verbalize understanding." There was no documentation why patient # 5 had a 22 hour delay from signing admission form to arrival at the facility. Patient was not able to consent when he arrived to the facility.

Based on document review, the facility failed to follow their own policy and respond to a grievance in a timely manner in 1 (patient #14) of 2 (patients #4 and #14) grievances reviewed.
Review of the facility's complaint and grievance log for November 1, 2015, through December 15, 2015, revealed a grievance was received via phone call from patient #14's spouse on November 4, 2015.
Review of the facility's "Grievance Report" documentation revealed staff #7 called patient #14's spouse on November 4, 2015 and discussed the grievance. The "Grievance Report" was signed by staff #7 and dated "10/30/2015", which was prior to the receipt of the grievance from patient #14's spouse.
There was no further documentation of contact, written or verbal, with patient #14 or the spouse until December 3, 2015, when a follow up letter dated December 2, 2015 was sent via certified mail to patient #14's spouse.
Review of the facility's policy titled, "Complaint & Grievance Process" revealed the following information:
"The facility shall have a written procedure for staff to follow when responding to client grievances. The facility shall:
1) Evaluate the grievance thoroughly and objectively, obtaining additional information as needed;
2) Provide a written response to the client within 7 days of receiving the grievance;
3) Take action to resolve all grievances promptly and fairly; and
4) Document all grievances, including the final disposition, and keep documentation in a central file."
The time span between the initial grievance and the written response to the patient #14's spouse was 29 calendar days, 22 days past the 7 day deadline.

Based on observation and interview the facility denied 13 of 13 (#1-#13) in-patients the right considerate and respectful care during meal service.

On 12/16/2015 at 7:20 the breakfast meals arrived from the contracted vendor. The meal arrived in individual aluminum "take out" containers, held in a red insulated bag. At 7:25 the Mental Health Tech (MHT) began to serve the meal. Meals were served to 13 of 13 patients in the "take out" container. The container was 10 inches long and 7 inches wide and 5 inches deep. The aluminum container had a 10 inch by 7 inch card board top that was held in place over the food by the aluminum edges of the container. The edges folded down to secure the lid. Each patient received a "take out" container with scrambled eggs, 1 round sausage patty and three french toast sticks. Each patient was given an individually packaged set of plastic eating utensils. Some patients were observed attempting, with difficulty, to cut up their french toast with the plastic fork which did not fit into the "take out" container easily. Staff was not observed offering assistance to those patient who were exhibiting difficulty in cutting up their food. Patients were observed eating their sausage and french toast with their fingers.

MHT #9 was asked if the meals were always served in the "take out" containers. She replied "yes".


On 12/16/2015 in the afternoon the Dietary Manager was interviewed. The Dietary manager confirmed the facility had no policy on what the patient's meals were served on.

Based on chart reviews and interviews, the facility failed to ensure the patients and patient representatives were provided information about the patients health status, diagnosis, and prognosis. The facility failed to ensure the patient was mentally capable of understanding consent for treatment, given their bill of rights, and correctly identifying a Legally Authorized Representative (LAR) in 3 (#3, 5, and 7) of 5 (#3, 5, 7, 8, 16) charts reviewed.

1.) Review of the Request for Voluntary Admission dated 12/8/15 at 7:00AM revealed the patient #7 signed the form but there was no witness signature date or time.

Review of the Patient Bill of Rights form revealed patient #7 signed the form on 12/8/15. However, the bottom of the form has the following questions that require a check if completed. All of the questions were blank;

I certify that:
I have received a copy of this four-page document prior to admission.
Staff have explained to me in a language I understand within 24 hours of admission (if involuntarily committed).
Staff have explained its contents to me in a language I understand prior to admission (if voluntarily committed).

There was no evidence found that patient #7 was given her bill of rights.

2.) Review of patient #3's chart revealed the patient was admitted to the facility on 12-4-15 at 5:15PM. Patient #3 was admitted with a diagnosis of Neurocognitive Disorder with Behavioral Disturbances, involuntarily on an Emergency Police Officers Warrant (EPOW). Patient #3 has had a negative psychiatric history. No psychotropic medications have ever been taken by patient #3.

Review of Consent for Treatment and the Patient Bill of Rights revealed they were blank. On the back of the consent a statement was written. The statement stated, "12/4/15 at 5:07PM Patient unable to sign in current condition. Uncontrollable crying."

Review of the Daily Multidisciplinary Note dated 12/5/15 at 5:46PM revealed staff # 30 met with patient #3 to finish her psych/social information. Staff #30 reported the patient was tearful and unable to give information to complete the assessment. The patients' granddaughter was called to gather the information needed. Staff #30 stated, "social worker discussed the patient's rights, confidentiality and the grievance process with the patient. Patient verbalized an understanding of all above." Review of the Nurses notes for 12/5/15 revealed the patient was confused.

Review of the Psychiatric Evaluation on 12/6/15 revealed patient #3 was notably labile with long periods of uncontrollable crying contrasted by long periods of bizarre laughter. Patient #3 had disorganized behavior and laughed inappropriately. Her reasoning is illogical and had loose associations.

There was no further evidence that patient #3 was given her bill of rights or had any conversation with staff regarding her Emergency Police Officers Warrant (EPOW) status or the application of an Order of Protective Custody (OPC).

Review of patient #3's Informed Consent for Psychotropic Medication revealed the patient did not sign consents. The following statement was written on the patient signature line, "Verbal consent received from the LAR-(granddaughter's name). "There was no found evidence that Patient #3 had a Legally Authorized Representative (LAR).

3.) Review of patient #5's chart revealed the patient was at a nursing home and was having some behavioral issues, confusion and sexually inappropriate. Review of the Request for Voluntary Admission form revealed on the patient signature line a squiggly line as patient #5's signature. On the back of the form staff #36 documented, "11/30/15 at 6:02PM I, staff #36 met with patient #5 on unit at patient #5's nursing home. Patient #5 was able to tell me his name that he was at the nursing home. I talked to him about placement at the facility. He states he is willing to admit to the facility for an inpatient placement and he voluntarily signed this paper for in-patient placement."

Review of the admission forms Patient Rights, Hospital Care Consent, Grievance Processes, were all blank. On the back of the forms was a statement from the RN, "12/1/15 4:30PM Pt unable to sign related to drowsy unable to verbalize understanding." There was no documentation why patient #5 had a 22 hour delay from signing admission form to arrival at the facility. Patient was not able to consent when he arrived to the facility.

Based on record review and interview, the facility failed to:
A. ensure the patients were safe from falls, report out of range blood pressures and critical glucose values, document safety measures while sleeping in day area and at nurses station, and implement nursing interventions to prevent falls in 2 (#3 and 16) out of 5 (#2, 3, 7, 8, and 16) patients reviewed.
B. follow their own policy requiring staff to visually observe patients every 15 minutes for location, activity, behavior and unsafe activities in 3 (patients #1, #6 and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.
C. provide laboratory services in a safe setting. The contracted laboratory provider
failed to follow facility policies and failed to demonstrate safe standards of infection control,when providing venipuncture for blood specimen collection, for 6 of 13 patients. The nursing staff failed to sanitize the dining room tables after venipuncture had been conducted, or prior to the breakfast meal being served for 13 of 13 patients.

A.) Review of patient #3's chart revealed the patient was admitted to the facility on 12-4-15 at 5:15PM. Patient #3 was admitted with a diagnosis of Neurocognitive Disorder with Behavioral Disturbances, involuntarily, on an Emergency Police Officers Warrant (EPOW). Patient #3 has had a negative psychiatric history. No psychotropic medications have ever been taken by patient #3.

Review of patient #3's daily nurse's notes revealed the patient was on fall precautions at high risk with a bed alarm on. Review of the Multi-Disciplinary Note dated 12/9/15 at 11:15AM stated, "Pt. rolled out of bed landing on the floor. Pt fell approx. 2 feet. Pt denied LOC or any pain or injuries. Pt had no visible injuries. Full body assess was performed, v/s taken, MSC-good no deformities, outward rotation, or shortening of the leg. Family, DR., and DON notified. Mats put on both sides of bed. Fall packet completed. Patient now sleeping and stable." There was no documentation of bed alarm.

According to the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health, blood pressure for adults is
Normal BP <120/<80 mmHg
Heart Rate: Female: 55-95 bpm
Respiration Rate: 12-18 breaths per minute

Review of patient #3's chart revealed a Neuro Flow sheet was started on patient #3 after the fall at 11:15PM. The following vital signs were taken as follows;
1.) 11:15PM- Review of the vital signs revealed the blood pressure was elevated at 162/107 and her heart rate was elevated at 120. Patient #3 has a history of atrial fibrillation and has a defibrillator.
2.) 11:30PM- blank on vital signs.
3.) 11:45PM- Blood pressure 150/90 and heart rate 110.
4.) 12:15AM- Blood pressure 163/85 and heart rate 60.

There was no nursing documentation found until 12/10/15 at 1:15AM. The nurse documented, "Continuing vital sign checks d/t fall earlier. Pt was agitated, crying d/t VS checks. BP was difficult to obtain, multiple attempts made. Final BP- 157/118, HR- 65, R 14, T- 97.7 O2 sat -99%. Pt laid back down and went back to sleep."There was no documentation that the physician was notified of the patient's hypertension. There was no documented evidence in the nurse's notes or physician progress notes that the physician was aware of the elevated blood pressure and heart rate.

There was no nursing documentation until three hours later at 4:00AM. The nurse documented "Pt. became extremely anxious and agitated with vs. She was crying loudly and wailing. MHT unable to assess BP and HR. BP- 153/82 HR- 72. Assessed pt. and respirations 16, even, unlabored, no cyanosis noted. Skin is warm and dry afebrile. Since vs agitate pt. too much at this time, directed MHT to skip 5:15AM vs will continue to check on pt." There was no documentation of any nursing interventions to help the distressed patient.

Review of the Vital Signs and I&O (Intake and Output) sheet revealed the patient's blood pressure was taken on the "day" shift at 148/111. There is no documented nurse's response to the elevated blood pressure, no documentation found that the physician was notified. There was no documented time when the blood pressure was taken. Review of the 7:00PM-7:00AM daily nurse's note stated patients BP was 148/11 "retake" 142/86. There is no documentation of when that VS was retaken.

Review of the MHT "Close Observation Check Sheet " revealed patient #3 was in room until 4:00AM on 12/10/15. At 4:14AM Patient #3 was in the dayroom sleeping. The nurse documented the patient had bed alarms on and mats by her bed but the patient was not in a bed according to the MHT notes. The MHT notes revealed patient #3 was not in a bed to rest until 8:30PM on 12/11/15 a total of 40 hours. There was no documentation of any nursing interventions, or attempts to allow patient to rest in a bed. There was no documentation that MD was made aware that patient had not been in a bed for 40 hours.

Review of the incident reports from October -December 2015 revealed there was no follow-up on the reports by the DPN or Patient Safety Officer.

Interview with DPN on 12/16/15 revealed she had not addressed any of the incident reports from falls for October- December. The DPN reported she has not had time.

Review of patient #16 revealed the patient was admitted to the facility on 11/11/15 at 7:30PM. Patient was admitted on an Emergency Police Officers Warrant (EPOW) and arrived to the facility by ambulance. Patient #16 was admitted with a diagnosis of Neurocognitive Disorder with Behavioral Disturbance and Delusional Disorder.

Review of the Multi-Disciplinary Notes dated 11/18/15 at 12:00AM revealed patient #16 was having chest pain. The nurse documented, "Patient yelling out and complaining of chest pain. When asked where he's hurting he placed his hand over his left chest. Head of bed is already elevated. When asked what his pain fells like, he replied the pain feels heavy. Vital signs taken; T- 97.4 P- 90, (pacemaker in place), R-18, unlabored BP-158/80, O2 sat- 100% Finger stick blood sugar 228. Skin pink, warm to touch, and dry. MD notified and given report on patients' condition. The patient does not appear to be in any distress. Orders received and carried out CMMS mobile x-ray notified of order."

Review of a telephone physician orders dated 11/18/15 at 12:15AM stated, "Do EKG; notify me of results if any changes noted in comparison of previous EKG." The order was not documented as a "STAT" order. There was no specifics in who was to read the EKG.

Review of the nurses notes date 11/18/15 at 1:35AM stated, "Staff from CMMS came and did EKG. Results of EKG called to MD. MD said to observe the patient and notify him if further complaints are voiced. Patient denies having chest pain at this time. He is awake and has disconnected the alarm pad on his bed. Alarm reconnected. Patient repositioned and made comfortable."

There was no further documentation of observation or care to patient #16 until 11/18/15 at 7:00AM, a 5 ½ hour time span.

Review of the physician progress note revealed the physician saw patient #16 on 11/18/15 at 6:00AM. MD wrote, "CP unclear no EKG changes. BS 100's-200's."

Review of the nurse's notes dated 11/18/15 at 9:06PM revealed the nurse documented, "Blood sugar taken at 9:00PM- 416, MD notified pt. asymptomatic ate bread, cookies, and baked chips for supper. No orders received will retake blood sugar in two hours, and at scheduled time 0600. Will monitor for s/sx of hyper/hypoglycemia."

Review of the admission physician orders revealed patient #16 was to be on a low NA (sodium) and LCS (low concentrated sweets). Nursing failed to adhere to the patients ordered diet.

Review of patient #16's chart revealed there was no nursing documentation found of patient assessment or recheck of patient #16's blood sugar until 6:00AM on 11/19/2015 a 9 hour delay.

Review of the nurse's notes on 11/19/15 at 8:45PM stated, "Blood sugar check results of 506 assessment done on pt. Pt. has no shaking. Skin warm and dry. Temp 98.2, HR 98, B/P 143/78, O2 sat 99%. BS recheck at 9:25PM results of 247 pt. asymptomatic. Will continue to monitor for s/s of hypoglycemia."

There was no documentation of nurse notifying MD of a 506 blood sugar or a nursing intervention. There was no found documentation of a glucometer error. The test sheet from the glucometer shows the glucometer was checked without failure.

An interview was conducted with DPN on 12/16/15 and staff #1 confirmed the findings above. The DPN reported that she had been trying to audit the charts and had the staff nurses auditing the charts. DPN confirmed nursing had not reported the elevated blood sugars to her.



35515


B.) A review of patient #1's record revealed a "Multi-Disciplinary Note" with the following documentation: "12/10/15 1120 (11:20 a.m.) NSG #1 Staff was making rounds and noticed patient getting out of bed. Staff entered the room and attempted to assist patient and he began calling her names. Staff asked patient if she could change his soiled clothes and again he began to call her out of her name and swung to hit her. Staff exited the room to get other staff to help patient in fear that he would fall ....12/10/15 1145 (11:45 a.m.) NSG #1 Patient continue calling staff names and trying to hit kick and spit on them. He hit one staff and kicked another ....". Further review of patient #1's record revealed a "Close Observation Check Sheet" dated 12/10/15. The MHT (Mental Health Tech) documented patient #1's location and activity from 8:00 a.m. until 12:00 p.m. as "in room sleeping". The documentation by the MHT contradicted the documentation by the nursing staff for this time period.

A review of patient #1's record revealed a "Multi-Disciplinary Note" with the following nursing documentation: "12/11/15 2030 (8:30 p.m.) NSG #1 Patient continue to be aggressive. Hitting staff. Calling staff out of their names. Attempted to distract patient by offering activities, snacks but patient refused and slapped staff. Patient calling staff 'black niggers'. Threatening to kill all black employees and workers. Patient sitting in dayroom being aggressive. Continue to monitor." Further review of patient #1's record revealed a "Close Observation Check Sheet" dated 12/11/15. The MHT (Mental Health Tech) documented patient #1's location and activity from 7:15 p.m. until 11:00 p.m. as "in room". The documentation by the MHT contradicted the documentation by the nursing staff for this time period.

A review of patient #1's record revealed a "Multi-Disciplinary Note" with the following nursing documentation: "12/12/15 2130 (9:30 p.m.) NSG #1 Patient is going door to door trying to get out 'I just got a page from my company. How do I get to the parking lot'. Pt is walking in the hallway. 'I need to use the phone, the shipment is coming in and I need to be there'. Pt (patient) returned to his room." Further review of patient #1's record revealed a "Close Observation Check Sheet" dated 12/12/15. The MHT (Mental Health Tech) documented patient #1's location and activity from 9:30 p.m. until 10:30 p.m. as "in dining room". The documentation by the MHT contradicted the documentation by the nursing staff for this time period.

A review of patient #1's record revealed a "Multi-Disciplinary Note" with the following nursing documentation: "12/13/15 2330 (11:30 p.m.) NSG #1 Pt continue to have aggressive behavior. Pacing up and down the halls making racial comments and threating to hit staff. Patient spit on one staff. Redirected patient to his room. Patient layed in floor and started kicking walls and door stating 'this is what I am going to do to all you n----'. Attempted to assist patient from floor and patient became anger stating 'don't touch me. I can lay on the floor if I want to. Get out of my room'. Staff at door monitoring patient." Further review of patient #1's record revealed a "Close Observation Check Sheet" dated 12/13/15. The MHT (Mental Health Tech) documented patient #1's location and activity from 7:15 p.m. until 12:15 a.m. (12/14/2015) as "in room sleeping". The documentation by the MHT contradicted the documentation by the nursing staff for this time period.

A review of patient #6's record revealed a "Multi-Disciplinary Note" with the following nursing documentation: "12/4/15 1415 (2:15 p.m.) NSG #1, #3 Pt ambulating down the hall shuffled gait, drowsy, arousable to verbal stimuli, staff #23 in clinic, received an order to hold 1800 (6:00 p.m.) dose of valium ...". Further review of patient #6's record revealed a "Close Observation Check Sheet" dated 12/4/15. The MHT (Mental Health Tech) documented patient #6's location and activity from 1:45 p.m. until 3:00 p.m. as "in room sleeping". The documentation by the MHT contradicted the documentation by the nursing staff for this time period.

A review of patient #6's record revealed a "Multi-Disciplinary Note" with the following nursing documentation: "12/1/15 9 p.m. NSG #1 Patient came down the hall yelling 'if she doesn't want to shake hands then I don't care, I hate her.' Patient goes back to his room in a fast pace yelling 'this is the fake (patient #6)'. Redirection was provided he went to his room to lay down." Further review of patient #6's record revealed a "Close Observation Check Sheet" dated 12/1/15. The MHT (Mental Health Tech) documented patient #6's location and activity from 9:00 p.m. until 9:45 p.m. as "in room sleeping". The documentation by the MHT contradicted the documentation by the nursing staff for this time period.

A review of patient #18's record revealed a "Multi-Disciplinary Note" with the following nursing documentation: "12/13/15 1800 (6:00 p.m.) NSG #4 Pt sitting in the dining room, calm visiting c (with) peers, alert, no c/o (complaint of) pain. B/P (blood pressure) taken manually 174/86, denies any headache, asymptomatic, given routine metoprolol. Will recheck B/P." Further review of patient #18's record revealed there was NO "Close Observation Check Sheet" for the date of 12/13/15 found.
A review of the facility's policy "TX-SPEC-05: Level of Observations/Monitoring" revealed the following information:

"Observation Levels:

Every 15 minutes - the staff member should visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities....

Close Observation Form:
The staff member utilizes the close observation form to document the location of the patient....

Procedure:
Every 15 Minute Observation:...
Assigned Nursing Staff (MHT):
· Circles/writes the type of specialty observation on the form (fall, suicide, etc.)....
· Physically walks to find each patient on q (every) 15 minute observation....
· Documents the location on the close observation form. Documents the activity when indicated (water offered, etc.)
· Initials the form every 15 minutes.
· Notifies the Charge nurse immediately of any patient who cannot be observed or located."




28659

C. Based on observation, interview and document review the facility failed to provide laboratory services in a safe setting. The contracted laboratory provider failed to follow facility policies and failed to demonstrate safe standards of infection control, when providing venipuncture for blood specimen collection, for 6 (#3, #6, #7, #8, #9, #10) of 13 patients. The nursing staff failed to sanitize the dining room tables after venipuncture had been conducted, or prior to the breakfast meal being served for 13 of 13 (#1-#13) patients.

On 12/15/2015 at 7:00 a.m., in the dining room of the psychiatric inpatient treatment unit, a contracted laboratory staff member was observed collecting blood specimens via venipuncture. Of the 13 inpatients observed in the dining room, the contracted laboratory phlebotomist collected 6 (#3, #6, #7, #8, #9, #10) individual patient blood specimens. The blood samples were collected as the patients sat around dining room tables waiting for their breakfast to be served. The phlebotomist placed the collection supply tray on the table top while the venipuncture was being completed. The phlebotomist was observed to pull a new pair of gloves from her right pocket and don the gloves prior to each venipuncture. She was not observed to wash her hands or use sanitizing hand gel at any time. Upon completing each venipuncture the phlebotomist removed her gloves turning them inside out. The phlebotomist then dropped the pair of contaminated gloves into the portable caddy, which held the clean venipuncture supplies. The phlebotomist pulled clean vacutainer sleeves, and specimen tubes from under the contaminated gloves. This process was repeated after each of the 6 (#3, #6, #7, #8, #9, #10) patient's had their blood samples taken.

Breakfast was served within 15 minutes of the completion of the blood specimen collection process. Blood droplet contamination could not be ruled out. The patients breakfast was placed on the same tables where the venipuncture collection process had occurred. The tables were not sanitized after the blood collection process or prior to placing the patient's breakfast on the tables.

On 12/16/2015 at 7:45 a.m., in the nurses station of the inpatient unit, an interview with the Chief Nursing Officer (CNO) revealed she had seen the phlebotomist as she exited the building, but had not observed her during any of the collection process. When the CNO was told of the surveyors observation, the CNO confirmed the phlebotomist should have drawn the patient's blood specimen in their room or in the examination room. She also confirmed the facility policy required two (2) patient identifiers be used for proper patient identificaiton. One being the arm band and the other being the patient's picture reference from the chart. She also confirmed hand washing was required between contact with each patient.

On 12/16/2015 at 9:30 a.m. in the conference room an interview with the Infection Control Officer revealed she had never supervised the collection of blood specimens in the facility, nor had she interviewed her staff regarding what they observed during the blood specimen collection process.

On 12/16/2015 in the afternoon, review of the following facility policies revealed:
IC-09 (Infection Control): Hand Hygiene: Employees will practice good hand hygiene between each patient. Hand hygiene includes wearing gloves when indicated, hand washing when indicated, decontamination with alcohol-based and antiseptics before and after each patient contact, avoid wearing artificial fingernails and keep natural nails less that one quarter of an inch if providing patient care and minimize risks of dermatitis.

IC-20: Specimen Collection. Policy: All specimens will be collected and transported in a safe manner. Purpose: To ensure patient specimens (urine, blood,etc) are collected, handled, stored and transported in a safe manner. Procedure: #6 Wash hands immediately after collection (of specimen).

IC-33 Management of accidental Blood or Body Exposure/Contamination Major Blood-borne Pathogens-HIV, HBV, and HCV. The OSHA (Occupational Safety Hazard Administration) standards are intended to protect workers from all known and as yet unknown diseases transmitted by blood.

IC-29 Dietary services IC. Policy: to ensure safety and infection prevention during the facility stay of the patient as in regards to food and drinks provided by the facility.
Purpose: to prevent and control contamination or the spread of infection within the department and the facility.

IC-18: Cleaning and Performing Low Level Disinfection of Medical Equipment, Devices, and Supplies. Policy: Equipment will be cleaned in a manner as to ensure minimal potential for the spread if organisms. Purpose: Provide guidelines for cleaning or disinfecting of patient care equipment dependent upon its uses in or on the body and its physical properties.

Based on record reviews and interviews the facility failed to have a tracking system for death in restraints.

Interview with staff # 2 on 12/15/15 confirmed there was no log or tracking system for reporting a patient death in restraints. Staff #2 reported they have had no deaths in restraints so there was nothing to put on a log. There was no mechanism found or offered to ensure a tracking device system was in place.

Based upon observation, record review and interview, the facility failed to:

A.) explain how the data collected and submitted were used in monitoring of effectiveness and safety of services and quality care.


Refer to Tag A0273


B.) track and analyze medical errors, falls, and medication errors to prevent adverse patient events.


Refer to Tag A0286


C.) have a mechanism to evaluate the quality of each contracted service in the QAPI process.


Refer to Tag A0308



D.) ensure that an ongoing program for quality improvement and patient safety (falls), including the reduction of medical and medication errors, is defined, implemented, and maintained.


Refer to Tag A0309

Based on reviews of Quality Assurance Performance Improvement (QAPI) materials and data, and interviews the facility failed to explain how the data collected and submitted were used in monitoring of effectiveness and safety of services and quality care.


Review of the QAPI materials revealed data was being gathered and put into a system reviewed by the corporate office. However, the QAPI manager for the facility had just started the position and was unable to communicate how the information was tracked and implemented in the facility.


An interview with staff #3 on 12/16/15 revealed staff #3 was transitioning from out of the QAPI role but had been collecting data and developing process improvements in the past. Staff# 3 reported she would collect data and send the information to corporate. The corporate office would make changes and send back process improvements and data to put in her book. Staff #3 reported there was a program they used but she was only able to give limited details in how the data was processed. Staff #3 reported the numbers she sends in for data is not always the same numbers that come back from corporate. Staff #3 reported that staff #4 had just started working on the QAPI process and had been doing the chart audits for monitoring the effectiveness and safety of services and quality of care for the last couple of months.


An interview with staff #4 was conducted on 12-15-15. Staff #4 was able to show the monitors she used to audit charts but was unsure how the process of monitoring for effectiveness of safety and quality of care was implemented.

Based on reviews of current incident reports, QAPI data/ measures, and interviews the facility failed to track and analyze medical errors, falls, and medication errors to prevent adverse patient events.


Review of the incident reports, including medical errors revealed there was no follow-up on the reports by the Director of Psychiatric Nursing (DPN) or Patient Safety Officer.

Review of 8 incident reports dated from 10/19/15 - 12/10/15 revealed the reports were filled out by the nurse and signed by the Director of psychiatric Nursing (DPN). There was no updates or investigations of the incidents by the DPN or Patient Safety Officer. There was no data found of these incident reports reported to QAPI.

Review of the Patient Incident & Occurrence Reporting Policy the QAPI Coordinator or department manager was to;
"Conference with personnel and parties involved.
Cosigns occurrence report and investigation form.
Recommends corrective action and follows up with appropriate department manager for implementation and follow through for immediate safety measures.
Utilizes data for performance improvement activities monthly.
Ensures all incidences minutes are evaluated/ investigated and documented is provided to show follow up and corrective actions."

Interview with DPN on 12/6/15 revealed she had not addressed any of the incident reports for October, November, or December of 2015. The DPN reported she has not had time.

Interview with Staff #3 on 12/16/15 revealed this information was not getting to the QAPI process.

Based on document review and interview, the facility failed to have a mechanism to evaluate the quality or secure information of each contracted service in the QAPI process.

Review of the contracted services revealed they were kept in two large black binders on a book shelf in the administrator's office. Inside the binders were contracts for Dieticians, Physical Therapist, and Occupational Therapist. The contracts had employee files attached with the personal information of the contractor such as social security numbers, salaries, bank account information, and W4's.

Review of the Quality Assessment and Performance Improvement (QAPI) plan for 2015 revealed no evidence that every contracted service was evaluated or followed in the QAPI plan.

An interview with the Administrator on 12/15/15 at 11:35 AM confirmed that she had not looked at the contracted services and was not aware that employee files were included in the contract book or if any contracts had expired.

An interview with staff #6 (HR) on 12/15/15 confirmed she was aware the contract book had vendor's sensitive personal information in them instead of the HR office where that information is secured. Staff #6 stated, "The last administrator insisted on keeping it like that in her office."

An interview with the staff #3 (QAPI) on 12/16/15 at 11:15 AM reported that contracts are discussed in the QAPI but there was no evidence presented from meetings to determine there is a mechanism to evaluate the quality of each contracted service. Staff #3 reported she was unaware of any expired contracts. Staff #3 reported the administrators had always kept up with the contracts. Staff #3 confirmed she had no knowledge of the contracted services or how they were evaluated.

Based on record reviews, review of the Quality Assessment and Performance Improvement (QAPI) meetings and data, interviews, and policy and procedures, the governing body failed to ensure that an ongoing program for quality improvement and patient safety (falls), including the reduction of medical and medication errors, was defined, implemented, and maintained.

Review of the incident reports, including medical errors revealed there was no follow-up on the reports by the Director of Psychiatric Nursing (DPN) or Patient Safety Officer.

Review of 8 incident reports dated from 10/19/15 - 12/10/15 revealed the reports were filled out by the nurse and signed by the DPN. There was no updates or investigations of the incidents by the DPN or Patient Safety Officer. There was no data found of these incident reports reported to QAPI.

Review of the Patient Incident & Occurrence Reporting Policy The QAPI Coordinator or department manager was to;
"Conference with personnel and parties involved.
Cosigns occurrence report and investigation form.
Recommends corrective action and follows up with appropriate department manager for implementation and follow through for immediate safety measures.
Utilizes data for performance improvement activities monthly.
Ensures all incidences minutes are evaluated/ investigated and documented is provided to show follow up and corrective actions."

Interview with DPN on 12/6/15 revealed she had not addressed any of the incident reports from October, November, or December of 2015. The DPN reported she has not had time.

Interview with Staff #3 on 12/16/15 revealed this information was not getting to the QAPI process.

Based upon observation, record review and interview, nursing failed to:


A.) properly assess patients with elevated blood pressures and blood sugars, nursing interventions, and document notification of critical lab values in 3(#3, 7, and 16) of 5(#3, 7, 8, 16 and 17) patients reviewed. The facility failed to ensure all patients received a complete nursing physical and psychological assessment every 12 hours in 2 (patients #8 and #16) of 5 (patients #1, #6, #8, #16, #17) records reviewed.


Refer to Tag A0395


B.) ensure orders taken by nursing staff from physicians were reviewed and signed by the ordering physician within 24 hours of the order initiation in 3 (patients #1, #6 and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.

Refer to Tag A0454

Based on chart reviews, Reviews of Quality Assessment Performance Improvement (QAPI), incident reports, and interviews the facility failed to properly assess patients with elevated blood pressures and blood sugars, nursing interventions, and document notification of critical lab values in 3(#3, 7, and 16) of 5(#3, 7, 8, 16 and 17) patients reviewed. The facility failed to ensure all patients received a complete nursing physical and psychological assessment every 12 hours in 2 (patients #8 and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.

1.) Review of patient #7's chart revealed she was a 58 year old admitted to the facility for Major depressive disorder, sever and general anxiety. Review of the Psychiatrist evaluation on 12/10/15 revealed patient #7's chief complaint, "I thought I had a brain tumor, but they feel that it is the Gabapentin that is making me so dizzy."

Review of patient #7's nursing admission notes patient #7 complained of ringing in the ears, blurred vision in her left eye. Review of the Comprehensive Integrated Assessment Intake Screen and Initial Level of Care Determination dated 12/7/15 revealed nurse documentation under Gravely Disabled. The nurse documented, "All of the sudden her ears started ringing last week. Since it has also caused her to feel sick. Unable to walk without holding onto walls, unable to concentrate and care for self for fear this ringing is going to make her die."

Review of the psychiatric evaluation the psychiatrist documented, "Medical History: Hypertension. Medical history is negative and patient #7 has no history of serious illness, injury, operation, or hospitalization. No medications are currently taken."

Review of patient #7's physician progress note dated 12/10/15 at 6:10AM revealed the patients' blood pressure was 96/59. There was no documentation of hypertension, ringing in the ears or dizziness noted on the progress note.

Review of patient #7's Nursing Multi-Disciplinary Note dated 12/10/15 at 8:43AM revealed DPN (Director of Psychiatric Nursing) documented, "BP at 0400 96/59, BP at 0815 145/97 Pt continues to c/o dizziness and ringing in ears. Encouraged pt. to request assistance with ambulation, slowly rise from lying or sitting position. Pt states understanding." There was no documentation found that the physician was notified of the elevated blood pressure, ringing in the ears or dizziness. There was no documentation found of a recheck of the blood pressure, or patient assessment for the 7:00AM-7:00PM shift.

Review of the Daily Nurses Notes for the 7:00PM -7:00AM shift on 12/10/15 revealed a blood pressure at the bottom of the page of 112/72. There was no time documented when this blood pressure was taken. There was a section on the note for the nurse to complete a Cardio/Pulmonary section about blood pressure or edema. This section was left blank. The nurses failed to document any communication to the physician, or assess the patient after elevated blood pressure and active symptoms.


2.) Review of patient #3's chart revealed the patient was admitted to the facility on 12-4-15 at 5:15PM. Patient #3 was admitted with a diagnosis of Neurocognitive Disorder with Behavioral Disturbances, involuntarily, on an Emergency Police Officers Warrant (EPOW). Patient #3 has had a negative psychiatric history. No psychotropic medications have ever been taken by patient #3.

Review of patient #3's daily nurse's notes revealed the patient was on fall precautions at high risk with a bed alarm on. Review of the Multi-Disciplinary Note dated 12/9/15 at 11:15AM stated, "Pt. rolled out of bed landing on the floor. Pt fell approx. 2 feet. Pt denied LOC or any pain or injuries. Pt had no visible injuries. Full body assess was performed, v/s taken, MSC-good no deformities, outward rotation, or shortening of the leg. Family, DR., and DON notified. Mats put on both sides of bed. Fall packet completed. Patient now sleeping and stable." There was no documentation of bed alarm.

According to the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health, blood pressure for adults is
Normal BP <120/<80 mmHg
Heart Rate: Female: 55-95 bpm
Respiration Rate: 12-18 breaths per minute
Blood Sugars- A normal sugar level is less than 100 mg/dL after not eating (fasting) for at least 8 hours. And it's less than 140 mg/dL 2 hours after eating.

Review of patient #3's chart revealed a Neuro Flow sheet was started on patient #3 after the fall at 11:15PM. The following vital signs were taken as follows;
1.) 11:15PM- Review of the vital signs revealed the blood pressure was elevated at 162/107 and her heart rate was elevated at 120. Patient #3 has a history of atrial fibrillation and has a defibrillator.
2.) 11:30PM- blank on vital signs.
3.) 11:45PM- Blood pressure 150/90 and heart rate 110.
4.) 12:15AM- Blood pressure 163/85 and heart rate 60.

There was no nursing documentation found until 12/10/15 at 1:15AM. The nurse documented, "Continuing vital sign checks d/t fall earlier. Pt was agitated, crying d/t VS checks. BP was difficult to obtain, multiple attempts made. Final BP- 157/118, HR- 65, R 14, T- 97.7 O2 sat -99%. Pt laid back down and went back to sleep." There was no documentation that the physician was notified of the patients' hypertension. There was no documented evidence in the nurse's notes or physician progress notes that the physician was aware of the elevated blood pressure and heart rate.

There was no nursing documentation until three hours later at 4:00AM. The nurse documented "Pt. became extremely anxious and agitated with vs. She was crying loudly and wailing. MHT unable to assess BP and HR. BP- 153/82 HR- 72. Assessed pt. and respirations 16, even, unlabored, no cyanosis noted. Skin is warm and dry afebrile. Since vs agitate pt. too much at this time, directed MHT to skip 5:15AM vs will continue to check on pt." There was no documentation of any nursing interventions to help the distressed patient.

Review of the Vital Signs and I&O (Intake and Output) sheet revealed the patient's blood pressure was taken on the "day" shift at 148/111. There is no documented nurse's response to the elevated blood pressure, no documentation found that the physician was notified. There was no documented time when the blood pressure was taken. Review of the 7:00PM-7:00AM daily nurse's note stated patients BP was 148/111 "retake" 142/86. There is no documentation of when that VS was retaken.

Review of the MHT "Close Observation Check Sheet" revealed patient #3 was in room until 4:00AM. At 4:14AM Patient #3 was in the dayroom sleeping. Documentation shows patient #3 was not in a bed to rest until 8:30PM on 12/11/15 a total of 40 hours. There is no documentation of any nursing interventions, or attempts to allow patient to rest in a bed. There is no documentation that MD was made aware that patient had not been in a bed for 40 hours. Patient is documented sleeping in the dayroom or at nurse's station.

Review of the incident reports from October- December 2015 revealed there was no follow-up on the reports by the Director of Physiciatric Nursing (DPN) or Patient Safety Officer.

Review of 8 incident reports dated from 10/19/15 - 12/10/15 revealed the report was filled out by the nurse and signed by the DPN. There was no updates or investigations of the incidents by the DPN or Patient Safety Officer. There was no data found of these incident reports reported to QAPI.

Review of the Patient Incident & Occurrence Reporting Policy the QAPI Coordinator or department manager was to;
"Conference with personnel and parties involved.
Cosigns occurrence report and investigation form.
Recommends corrective action and follows up with appropriate department manager for implementation and follow through for immediate safety measures.
Utilizes data for performance improvement activities monthly.
Ensures all incidences minutes are evaluated/ investigated and documented is provided to show follow up and corrective actions."

Interview with DPN on 12/16/15 revealed she had not addressed any of the incident reports from falls from October - December 2015. The DPN reported she has not had time.

Interview with Staff #3 on 12/16/15 revealed this information was not getting to the QAPI process.

3.) Review of patient #16 revealed the patient was admitted to the facility on 11/11/15 at 7:30PM. Patient was admitted on an Emergency Police Officers Warrant (EPOW) and arrived to the facility by ambulance. Patient #16 was admitted with a diagnosis of Neurocognitive Disorder with Behavioral Disturbance and Delusional Disorder.

Review of the Multi-Disciplinary Notes dated 11/18/15 at 12:00AM revealed patient #16 was having chest pain. The nurse documented, "Patient yelling out and complaining of chest pain. When asked where he's hurting he placed his hand over his left chest. Head of bed is already elevated. When asked what his pain fells like, he replied the pain feel heavy. Vital signs taken; T- 97.4 P- 90, (pacemaker in place), R-18, unlabored BP-158/80, O2 sat- 100% Finger stick blood sugar 228. Skin pink, warm to touch, and dry. MD notified and given report on patients' condition. The patient does not appear to be in any distress. Orders received and carried out CMMS mobile x-ray notified of order."

Review of a telephone physician orders dated 11/18/15 at 12:15AM stated, "Do EKG; notify me of results if any changes noted in comparison of previous EKG." The order was not documented a "STAT" order. There was no specifics in who was to read the EKG.

Review of the nurses notes date 11/18/15 at 1:35AM stated, "Staff from CMMS came and did EKG. Results of EKG called to MD. MD said to observe the patient and notify him if further complaints are voiced. Patient denies having chest pain at this time. He is awake and has disconnected the alarm pad on his bed. Alarm reconnected. Patient repositioned and made comfortable."

There was no further documentation of observation or care to patient #16 until 11/18/15 at 7:00AM, a 5 ½ hour time span.

Review of the physician progress note revealed the physician saw patient #16 on 11/18/15 at 6:00AM. MD wrote, "CP unclear no EKG changes. BS 100's-200's."

Review of the nurses notes dated 11/18/15 at 9:06PM revealed the nurse documented, " Blood sugar taken at 9:00PM- 416, MD notified pt. - asymptomatic ate bread, cookies, and baked chips for supper. No orders received will retake blood sugar in two hours, and at scheduled time 0600. Will monitor for s/sx of hyper/hypoglycemia."

Review of the admission physician orders revealed patient #16 was to be on a low NA (sodium) and LCS (low concentrated sweets). Nursing failed to adhere to the patients ordered diet.

Review of patient #16's chart revealed there was no nursing documentation found of patient assessment or recheck of patient #16's blood sugar until 6:00AM on 11/19/2015 a 9 hour delay.

Review of the nurse's notes on 11/19/15 at 8:45PM stated, "Blood sugar check results of 506 assessment done on pt. Pt. has no shaking. Skin warm and dry. Temp 98.2, HR 98, B/P 143/78, O2 sat 99%. BS recheck at 9:25PM results of 247 pt. asymptomatic. Will continue to monitor for s/s of hypoglycemia."

There was no documentation of nurse notifying MD of a 506 blood sugar or a nursing intervention. There was no found documentation of a glucometer error. The test sheet from the glucometer shows the glucometer was checked without failure.

An interview was conducted with DPN on 12/16/15 and staff #1 confirmed the findings above. The DPN reported that she had been trying to audit the charts and had the staff nurses auditing the charts. DPN confirmed nursing had not reported the elevated blood sugars to her.











35515


Review of patient #8's medical record on 12/15/2015 at 10:00 a.m. revealed there was NO nursing physical or psychological assessment found for the 12 hour period of 7:00 a.m. until 7:00 p.m. on 12/14/2015.

Review of patient #18's medical record on 12/15/2015 at 10:30 a.m. revealed there was NO nursing physical or psychological assessment found for the 12 hour period of 7:00 a.m. until 7:00 p.m. on 12/13/2015.

Review of the facility's policy titled, "NSG-02: Documentation", revealed the following information:
"Policy: Nursing service personnel document on the Daily Nurse's Note and in the integrated progress notes.
Documentation is done on every shift, incorporating the elements of the nursing process and including treatment plan ....
Documentation:
Inpatient:
· RN/LVN documents on the Daily Nurse's Note a minimum of once per shift or at the time any pertinent event occurs."

Based on record review and document review, the facility failed to ensure orders taken by nursing staff from physicians were reviewed and signed by the ordering physician promptly following order initiation in 3 (patients #1, #6 and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.
Review of patient #1's record on 12/15/2015 at 1:15 p.m. revealed 3 orders that had NO physician signature as follows:
1. On 12/10/2015, an order was written by staff #28 that stated, "12/10/15 2315 (11:15 p.m.) Geodon 10 mg IM (intramuscular) X 1 dose now for severe agitation and aggression. RBVO (read back verbal order): Staff #12/Staff #28". No physician signature was found 110 hours after the order was initiated.
2. On 12/11/2015, an order was written by staff #35 that stated, "12-11(-2015) 0645 (6:45 a.m.) Zyprexa Zydis 10 mg PO (by mouth) X 1 time Per staff #12/Staff #35". No physician signature was found 102.5 hours after the order was initiated.
3. On 12/12/2015, an order was written by staff #20 that stated, "12/12 (2015) 1) D/C (discontinue) Risperdal 2) Start Geodon 20 mg PO (by mouth) BID (twice daily) at 0600 (6:00 a.m.) & 1800 (6:00 p.m.) - agitation/aggression - RBVO (read back verbal order) staff #12/Staff #20". No physician signature was found and the order did not contain a time it was written.

Review of patient #6's record on 12/15/2015 at 1:45 p.m. revealed 2 orders that had NO physician signature as follows:
1. On 11/24/2015, an order was written by staff #20 that stated, "11-24-15 1700 (5:00 p.m.) Clonidine 0.1 mg (milligram) now then PRN (as needed) Q (every) 8 (hours) for BP (blood pressure) over 160/90 - HTN (hypertension). Start Lisinopril/HCTZ (Hydrochlorothiazide) 20/125 mg 1 PO (by mouth) Q daily in a.m. for HTN----RBVO (read back verbal order) staff #22/staff #20". No physician or nurse practitioner signature was found 500 hours and 45 minutes (20 days, 20 hours and 45 minutes) after the order was initiated.
2. On 11/30/2015, an order was written by staff #11 that stated, "11/30/15 1840 (6:40 p.m.) 1) Multivitamin once daily 2) Ensure 1 can bid (twice daily) RBVO (read back verbal order) staff #12/staff #11". No physician signature was found 355 hours and 5 minutes (14 days, 19 hours, 5 minutes) after the order was initiated.

Review of patient #18's record on 12/15/2015 at 10:30 a.m. revealed 3 orders that had NO physician signature as follows:
1. On 12/11/2015, an order was written by staff #5 that stated, "12/11/15 1900 (7:00 p.m.) Admit to the services of staff #12 upon arrival to the facility. Diagnosis: Major Depressive Disorder Recurrent Severe c (with) Psychotic Features RBVO (read back verbal order) staff #12/staff #5". No physician signature was found 87.5 hours after the order was initiated.
2. On 12/11/2015, a "Physician Order/Admission Medication Reconciliation" form was completed and signed by staff #21 as follows, "RBVO (read back verbal order) NSG (nursing) Signature staff #21 per staff #12 date 12/11/15 time 2250 (10:50 p.m.)" No physician signature was found 83 hours and 40 minutes after the order was initiated.
3. On 12/11/2015, a "Admit Orders/Initial Plan of Care" form was completed and signed by staff #5 as follows, "Nurse Receiving Orders/RBVO: staff #5 Date/Time: 12/11/15 2250 (10:50 p.m.) Physician/Date/Time:__________________". No physician signature was found 83 hours and 40 minutes after the order was initiated.

Based upon observation, record review and interview, the facility failed to:

A.) provide evidence the management (Administrator, Governing Body and Medical Staff) were aware of how the contracted laboratory services were being provide. The management had not required the laboratory service, to provide a method to monitor their service or a CLIA (Clinical Laboratory Improvement Amendment) certification to verify their service.

Refer to Tag A0582


B.) follow the policies of the contracting hospital for infection control in 6 of 13 patients identified.

Refer to Tag A0585

Based on observation, interview and document review the facility failed to provide evidence the management (Administrator, Governing Body and Medical Staff) were aware of how the contracted laboratory services were being provide. The management had not required the laboratory service, to provide a method to monitor their service or a CLIA (Clinical Laboratory Improvement Amendment) certification to verify their service.

On 12/15/2015 at 7:00 a.m., in the dining room of the psychiatric inpatient treatment unit, a contracted laboratory staff member was observed collecting blood specimens via venipuncture. Of the 13 inpatients observed in the dining room, the contracted laboratory phlebotomist collected 6 individual patient blood specimens. The blood samples were collected as the patients sat around dining room tables waiting for their breakfast to be served. The phlebotomist placed the collection supply caddy on the table top while the venipuncture was being completed. The phlebotomist was observed to pull a new pair of gloves from her right pocket and don the gloves prior to each venipuncture. She was not observed to wash her hands or use sanitizing hand gel at any time. Upon completing each venipuncture the phlebotomist removed her gloves turning them inside out. The phlebotomist then dropped the pair of contaminated gloves into the portable caddy, which held the clean venipuncture supplies. The laboratory technician pulled clean vacutainer sleeves, and specimen tubes from under the contaminated gloves. This process was repeated after each of the 6 patients had their blood samples taken.

On 12/16/2015 at 7:40 a.m., in the nurses station of the in patient unit an interview with the Chief Nursing Officer (CNO) revealed she had seen the laboratory technician as she exited the building but had not observed her during any of the collection process. When the CNO was told of the surveyor's observation she confirmed the lab should have been drawn in the patient's room or in the examination room. The policy required two (2) patient indicators, review of the arm band and the picture reference from the chart. She further confirmed hand washing was required between each patient.

On 12/16/2015 at 9:30 a.m. in the conference room an interview with the Infection Control Officer revealed she had never supervised the collection of blood specimens in the facility, nor had she interviewed her staff regarding what they observed during the blood specimen collection process.

On 12/16/2015 in the afternoon, review of the following facility policies revealed:
IC-09 (Infection Control): Hand Hygiene: Employees will practice good hand hygiene between each patient. Hand hygiene includes wearing gloves when indicated, hand washing when indicated, decontamination with alcohol-based and antiseptics before and after each patient contact, avoid wearing artificial fingernails and keep natural nails less that one quarter of an inch if providing patient care and minimize risks of dermatitis.

IC-20: Specimen Collection. Policy: All specimens will be collected and transported in a safe manner. Purpose: To ensure patient specimens (urine, blood,etc) are collected, handled stored and transported in a safe manner. Procedure: #6 Wash hands immediately after collection (of specimen).

IC-33 Management of accidental Blood or Body Exposure/Contamination Major Blood-borne Pathogens-HIV, HBV, and HCV. The OSHA (Occupational Safety Hazard Administration) standards are intended to protect workers from all known and as yet unknown diseases transmitted by blood.

IC-29 Dietary services IC. Policy: to ensure safety and infection prevention during the facility stay of the patient as in regards to food and drinks provided by the facility.
Purpose: to prevent and control contamination or the spread of infection within the department and the facility.

IC-18: Cleaning and Performing Low Level Disinfection of Medical Equipment, Devices, and Supplies. Policy: Equipment will be cleaned in a manner as to ensure minimal potential for the spread if organisms. Purpose: Provide guidelines for cleaning or disinfecting of patient care equipment dependent upon its uses in or ion the body and its physical properties.

The contracted laboratory service provider, provided a phlebotomist who demonstrated poor infection control practice for services that required collection of blood specimens from 6 patients.

On 12/16/2015 in the conference room the contract for provision of laboratory service was reviewed and revealed the following:Page 1 "specific Individual(s) performing Service(s); On such days and times as follow: Phlebotomy and specimen transport once daily between 6:30 a.m. and 8:00 a.m. (sic) days/week; Laboratory testing of patient samples as requested 7 days per week/24 hours per day". Page "2 item #1 Independent Contractor's Obligations. 1.4 Regulatory compliance. Independent Contractor shall perform all duties under this Agreement in strict compliance with federal, state, and local law, rules and regulations, including without limitations all laws relating to the Independent Contractor's Services in the state where Facility is located ("State"), the prevailing community standard of care in the community served by each Facility, and if applicable, facilities's bylaws, policies, procedures, rules and regulations, and the medical applicable standards".

The contract failed to establish how the services they provided would be monitored for compliance with the, "strict compliance with federal, state, and local law, rules and regulations, including without limitations all laws relating to the Independent Contractor's Services in the state where Facility is located ("State"), the prevailing community standard of care in the community served by each Facility, and if applicable, facilities's bylaws, policies, procedures, rules and regulations, and the medical applicable standards". Further, the contractor failed to provide a copy of the CLIA certificate for their laboratory service.

On 12/16/2015 in the conference room an interview with the Infection Control Officer confirmed she did not have a copy of the CLIA certificate in her Infection Control documentation. Further conversation with the Infection Control Officer confirmed to her knowledge no one from the contracted service had contacted the facility for satisfaction with their service, no one had participated in any infection control quality performance issue. Further the Infection Control Officer also confirmed the management ( administrator, Governing Body representative, Medical staff representative) had never observed or questioned the manner in which the laboratory services were provided.

The Infection Control Officer confirmed that, although laboratory services were included in the infection control report. No one had observed the laboratory provider at the service point with the patients. She was unaware the Phlebotomist had such poor infection control practices.

Based on document review and interview, the facility failed to:

A). ensure their Utilization Plan provided for review of services furnished by the facility and by members of the facility's medical staff.

Review of the facility's document titled, "Plan for Utilization Review 2015" revealed the following information: "The goals and objectives of the Utilization Review process are carried out by either a UR Committee, Subgroup of the UR Committee, or a designee of the UR Committee." There was no further documentation related to Utilization Review provided by the facility.


An interview with staff #1 on 12/16/2015 revealed the facility had not appointed a Utilization Review Committee nor had they initiated above mentioned Utilization Plan for 2015.


B). ensure their Utilization Review Plan had an appointed Utilization Review Committee, Subgroup or designee to initiate and enforce the plan.

Refer to tag A0654

Based on document review and interview, the facility failed to ensure their Utilization Plan provided for review of services furnished by the facility and by members of the facility's medical staff.


Review of the facility's document titled, "Plan for Utilization Review 2015" revealed the following information: "The goals and objectives of the Utilization Review process are carried out by either a UR Committee, Subgroup of the UR Committee, or a designee of the UR Committee."

An interview with staff #1 on 12/16/2015 revealed the facility had not appointed a Utilization Review Committee, Subgroup or designee to initiate and enforce the plan.

Based on observation, document review and interview the facility failed to provide a sanitary environment for laboratory services (collection of blood specimens). Potential for cross contamination related to poor hand hygiene, unsanitary disposal of contaminated gloves and use of contaminated laboratory supplies for the collection of individual patient blood specimens for 6 (#3, #6, #7, #8, #9, #10) of 13 patients observed. The facility also failed to provide a sanitary environment during the service of breakfast. Blood droplet contamination could not be ruled out after laboratory blood specimens were collected at the dining room tables for 13 of 13 (#1-#13) patients.

On 12/15/2015 at 7:00 a.m., in the dining room the psychiatric inpatient treatment unit, a contracted laboratory staff member was observed collecting blood specimens via venipuncture. Of the 13 inpatients observed in the dining room, the contracted laboratory phlebotomist collected 6 (#3, #6, #7, #8, #9, #10) individual patient blood specimens. The blood samples were collected as the patients set around a dining room table waiting for their breakfast to be served. The phlebotomist was observed to pull a new pair of gloves from her right pocket and don the gloves prior to each venipuncture. She was not observed to wash her hands or use sanitizing hand gel at any time. Upon completing each venipuncture the phlebotomist removed her gloves turning them inside out while holding a contaminated 2 x 2 gauze and the tourniquet used on the patient. The phlebotomist dropped each set of contaminated gloves into the portable caddy which held the clean venipuncture supplies. This process was repeated after each of the 6 patient's had their blood samples taken.

Breakfast was served within 15 minutes of the completion of the blood specimen collection process. The patients breakfast containers were placed on the tables where each patient eat their meal. The tables were not sanitized after the blood collection process or prior to placing the patient's meal tray on the table surface.


On 12/16/2015 at 9:30 a.m. in the conference room an interview with the Infection Control Officer revealed she had never supervised the collection of blood specimens in the facility, nor had she interviewed her staff regarding what they observed during the blood specimen collection process.

On 12/16/2015 in the afternoon, review of the following facility policies:
IC-09 (Infection Control): Hand Hygiene: Employees will practice good hand hygiene between each patient. Hand hygiene includes wearing gloves when indicated, hand washing when indicated, decontamination with alcohol-based and antiseptics before and after each patient contact, avoid wearing artificial fingernails and keep natural nails less that one quarter of an inch if providing patient care and minimize risks of dermatitis.

IC-20: Specimen Collection. Policy: All specimens will be collected and transported in a safe manner. Purpose: To ensure patient specimens (urine, blood,etc) are collected, handled stored and transported in a safe manner. Procedure: #6 Wash hands immediately after collection (of specimen).

IC-33 Management of accidental Blood or Body Exposure/Contamination Major Blood-borne Pathogens-HIV, HBV, and HCV. The OSHA (Occupational Safety Hazard Administration) standards are intended to protect workers from all known and as yet unknown diseases transmitted by blood.

IC-29 Dietary services IC. Policy: to ensure safety and infection prevention during the facility stay of the patient as in regards to food and drinks provided by the facility.
Purpose: to prevent and control contamination or the spread of infection within the department and the facility.

IC-18: Cleaning and Performing Low Level Disinfection of Medical Equipment, Devices, and Supplies. Policy: Equipment will be cleaned in a manner as to ensure minimal potential for the spread if organisms. Purpose: Provide guidelines for cleaning or disinfecting of patient care equipment dependent upon its uses in or ion the body and its physical properties.

The Infection Control Officer failed to ensure established Infection Control Policies were followed.

Based on record review the facility failed to ensure each patient admitted had a psychiatric evaluation by a licensed psychiatrist present in the medical record within 60 hours of admission in 3 (patients #8, #17, and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.
Review of patient #8's medical record on 12/15/2015 at 10:00 a.m. revealed an admission time of 12/10/2015 at 7:30 p.m. 110.5 hours after patient #8 was admitted to the facility, there was NO psychiatric evaluation found in the record.
Review of patient #17's medical record on 12/15/2015 at 11:00 a.m. revealed an admission time of 12/11/2015 at 12:25 p.m. 94 hours and 35 minutes after patient #17 was admitted to the facility, there was NO psychiatric evaluation found in the record.
Review of patient #18's medical record on 12/15/2015 at 10:30 a.m. revealed an admission time of 12/11/2015 at 10:50 p.m. 83 hours and 40 minutes after patient #18 was admitted to the facility, there was NO psychiatric evaluation found in the record.

Based on chart reviews and interviews the facility failed to have specifically described modality approaches. It was not clear that the active treatment and education received by the patient was consistent and personalized for the patient in 2 (#7, 3) out of 5 (#7, 3, 8, 16, 2) charts reviewed.

1.) Review of patient #7's treatment plan modality under Alteration of Mood R/T Depression revealed, Nursing will:
" Provide education on s/sx of disease process:
1.) During nursing groups x 45-60min 1 x per week x 3 weeks. 1:1 with patient 7 x per week x 3 weeks.
2.) Provide education on prescribed medications: During Nsg groups x 45-60min 1 x per week x 3 weeks. 1:1 with patient 7 x per week x 3 weeks.
Social work will;
Provide 1:1 counseling as ordered by physician to address topics as needed.
Provide family therapy as ordered by physician to address topics as needed.
There was no documentation of what type of disease process or what type of education. There are no medications listed or what type of education will be needed. Social work used "topics as needed" in a generalized way with no specific description.
Interview with staff #2 and staff #7 on 12/16/15 confirmed the treatment plans are incomplete and staff still lack understanding of the treatment plan process.
Review of patient #3's daily nurse's notes revealed the patient was on fall precautions at high risk with a bed alarm on. Review of the Multi-Disciplinary Note dated 12/9/15 at 11:15AM stated, "Pt. rolled out of bed landing on the floor. Pt fell approx. 2 feet. Pt denied LOC or any pain or injuries. Pt had no visible injuries. Full body assess was performed, v/s taken, MSC-good no deformities, outward rotation, or shortening of the leg. Family, DR., and DON notified. Mats put on both sides of bed. Fall packet completed. Patient now sleeping and stable." There was no documentation of bed alarm.
According to the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health, blood pressure for adults is
Normal BP <120/<80 mmHg
Heart Rate: Female: 55-95 bpm
Respiration Rate: 12-18 breaths per minute

2.) Review of patient #3's chart revealed a Neuro Flow sheet was started on patient #3 after the fall at 11:15PM. The following vital signs were taken as follows;
1.) 11:15PM- Review of the vital signs revealed the blood pressure was elevated at 162/107 and her heart rate was elevated at 120. Patient #3 has a history of atrial fibrillation and has a defibrillator.
2.) 11:30PM- blank on vital signs.
3.) 11:45PM- Blood pressure 150/90 and heart rate 110.
4.) 12:15AM- Blood pressure 163/85 and heart rate 60.
There was no nursing documentation found until 12/10/15 at 1:15AM. The nurse documented, "Continuing vital sign checks d/t fall earlier. Pt was agitated, crying d/t VS checks. BP was difficult to obtain, multiple attempts made. Final BP- 157/118, HR- 65, R 14, T- 97.7 O2 sat -99%. Pt laid back down and went back to sleep." There was no documentation that the physician was notified of the patients' hypertension. There was no documented evidence in the nurse's notes or physician progress notes that the physician was aware of the elevated blood pressure and heart rate.
There was no nursing documentation until three hours later at 4:00AM. The nurse documented, "Pt. became extremely anxious and agitated with vs. She was crying loudly and wailing. MHT unable to assess BP and HR. BP- 153/82 HR- 72. Assessed pt. and respirations 16, even, unlabored, no cyanosis noted. Skin is warm and dry afebrile. Since vs agitate pt. too much at this time, directed MHT to skip 5:15AM vs will continue to check on pt." There was no documentation of any nursing interventions to help the distressed patient.
Review of the Vital Signs and I&O sheet revealed the patient's blood pressure was taken on the "day" shift at 148/111. There is no documented nurse's response to the elevated blood pressure, no documentation found that the physician was notified. There was no documented time when the blood pressure was taken. Review of the 7:00PM-7:00AM daily nurse's note stated patients BP was 148/11 "retake" 142/86. There is no documentation of when that VS was retaken.
Review of the treatment plan under High Risk for Falls revealed there was no documentation on the plan about the patients' fall on 12/9/15. The target date for 12/16 was crossed out and an E put in for Extended. The extended date was 12/23/15. There was no specific modalities changed or documented on the plan that was tailored for patient #3. The modalities checked for Nursing was blank.
"Provide education on s/sx of disease process was checked on the list but left blank.
1.) During nursing groups x 45-60min___ x per week x ____ weeks. 1:1 with patient___ x per week x ___ weeks. This was blank.
2.) Provide education on prescribed medications: During Nsg groups x 45-60min 7 x per week x 2 weeks. 1:1 with patient ___ x per week x ____ weeks. This was also blank.
Review of the Alteration in Health Maintenance revealed no update or mention of the patients' elevated blood pressures. The target date for 12/16 was crossed out and an E put in for Extended. The extended date was 12/28/15. Review of the modalities for provide education for health maintenance activities was checked but left blank.
There was no documentation of what type of disease process or what type of education. There are no medications listed or what type of education will be needed.

Based on record reviews and interviews the facility failed to include problems, interventions, modalities, and goals that reflected the nursing progress notes. The facility failed to ensure a written plan that adequately documented the treatment given to the patient and record the patient responses.

Review of patient #7's nursing admission notes patient #7 complained of ringing in the ears, blurred vision in her left eye. Review of the Comprehensive Integrated Assessment Intake Screen and Initial Level of Care Determination dated 12/7/15 revealed nurse documentation under Gravely Disabled. The nurse documented, "All of the sudden her ears started ringing last week. Since it has also caused her to feel sick. Unable to walk without holding onto walls, unable to concentrate and care for self for fear this ringing is going to make her die."

Review of the psychiatric evaluation the psychiatrist documented, "Medical History: Hypertension. Medical history is negative and patient #7 has no history of serious illness, injury, operation, or hospitalization. No medications are currently taken."

Review of patient #7's physician progress note dated 12/10/15 at 6:10AM revealed the patients' blood pressure was 96/59. There was no documentation of hypertension, ringing in the ears or dizziness noted on the progress note.

Review of patient #7's Nursing Multi-Disciplinary Note dated 12/10/15 at 8:43AM revealed DPN documented, "BP at 0400 96/59, BP at 0815 145/97 Pt continues to c/o dizziness and ringing in ears. Encouraged pt. to request assistance with ambulation, slowly rise from lying or sitting position. Pt states understanding. "There was no documentation found that the physician was notified of the elevated blood pressure, ringing in the ears or dizziness. There was no documentation found of a recheck of the blood pressure, or patient assessment for the 7:00AM-7:00PM shift.

Review of the treatment plan revealed there was no documented problem for patient #7's complications of hypertension, ringing in the ears, blurred vision or weakness. Patient #7 was ordered Meclizine for vertigo. The nurse placed the medication for education on the treatment plan but did not create a problem with modalities.