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Based on staff interviews and record review the Conditon of Nursing Services was not met as evidenced by staff failure to provide patient care in accordance with the facility's policy and protocols and to conduct ongoing health status assessments when there is an identified change in patient condition.


Refer to A-0395 and A-0405

Based on staff interview and record review nursing staff failed to follow the facility's policies and protocol for medication administration and safety searches, and failed to assure the ongoing evaluation and assessment of patient care needs and health status for 3 patients. (Patient's #1, #2 and #20). Findings include:

1. Per record review staff failed to follow the facility's policy titled Administration and Scheduled Time of Medication, last revised and approved in July of 2011, which stated: III. Verifications, Education and Discussion: "Before administering medication staff will: Verify that there is no contraindication for administering the medication." In addition the facility's protocol for responding to missing medication, titled Safety Searches - Unit Lock-down for Contraband, dated June 2006, which stated; "All medication passes are to be halted and no medication may be given until cleared with the Unit Manager or Supervisor", was not followed.

Per record review Patient #1, who was admitted to the Tyler 2 Unit on 1/18/12 for treatment of suicidal ideation and alcohol detox., was able to obtain and ingest the Methadone (opiate) prescribed for Patient #2 during a medication (med) pass on the morning of 1/19/12. Per interview, at 3:20 PM on 1/24/12, Nurse #1 who was responsible for med pass for all patients on Tyler 2 on 1/19/12, stated that s/he was inside the med room that morning with the bottom half of the Dutch style door to the room closed. S/he stated s/he had prepared medications for several patients and placed the meds in individual plastic med cups, identified by patient name, on the top of the med cart which was located next to the door and within arm's reach of someone standing outside the door. Nurse #1 stated that Patient #1 presented at the med room door for his/her medication at approximately 9:00 or 9:30 AM that day. S/he stated that the patient, who was on an alcohol detox program had an assessment conducted by his/her primary nurse, in accordance with the Alcohol Detox protocol, that identified a score which required administration of 75 mg of Librium (benzodiazipine used to relieve anxiety and control agitation caused by alcohol withdrawal) . Nurse #1 stated that s/he administered the Librium and Patient #1 continued to stand leaning on the shelf of the half door repeatedly requesting Ritalin, for which there was no physician order, while other patients lined up in the hallway awaiting their turns for med administration. Nurse #1 stated that s/he had turned his/her head away from the patient for a short period just once during the exchange with Patient #1. Following the exchange, Patient #1 left the area of the med room and the nurse continued to administer meds to other patients. Nurse #1 stated it was within 15 minutes of the exchange with Patient #1 that Patient #2 presented to the med room door asking for their daily maintenance dose of 110 mg of Methadone and the nurse was not able to find the pre-poured medication. S/he stated s/he had previously prepared the (2) 40 mg wafers and (6) 5 mg tablets to total the 110 mg dose, placed them in a plastic med cup with another plastic med cup covering it and placed it on top of the med cart. Nurse #1 stated that s/he alerted other staff and the Pharmacy that the Methadone was missing. S/he stated that, with the assistance of a pharmacy technician, they searched, unsuccessfully, throughout the med room for the Methadone. The protocol for Safety Searches - Unit Lock down for Contraband was implemented immediately following the identification of missing Methadone; patients were gathered in the community area as individual room searches were conducted and the process of obtaining urine for drug screening was initiated on all patients. Nurse #1 stated that, during this time, although s/he had not consulted Patient #2's attending physician, s/he did speak with a Pharmacist about providing the maintenance dose of Methadone to Patient #2 who had still not received the medication. Despite the fact that administration of Methadone to Patient #2 was contraindicated because staff had not been able to account for the missing Methadone, it was not in accordance with the protocol that stated to halt all medication administration, and, finally, without consulting with the attending physician or Nurse Manager, Nurse #1 confirmed that s/he administered 110 mg of Methadone to Patient #2 (at 9:30 AM according to the Medication Administration Record). In addition Nurse #1 stated that s/he continued to administer medication to the 3 or 4 patients that had still not received their scheduled medications.

During interview, at 3:45 PM on 1/24/12, Nurse #2, the Charge Nurse on Tyler 2 on 1/19/12, confirmed that following the identification of the missing Methadone the Nurse Manager, Supervisor and Physicians on the unit were all notified; the patients were gathered in the community area and room searches were conducted on the individual patient rooms. Nurse #2 stated that during this period Patient #1 approached him/her and admitted that s/he had found a white pill (a 40 mg wafer of Methadone) on the floor of the bathroom that morning and had ingested it. A body search was then conducted on Patient #1 and during the contraband search of Patient #1's room s/he revealed a 5 mg tablet of Methadone that had been taped to the underside of a drawer. Patient #1 was placed on 1:1 observation status and after beginning to exhibit symptoms of Methadone overdose, including slurred speech, decreased respirations, increasing lethargy and constricted pupils, s/he was transferred, at 11:55 AM, to the ER (Emergency Room) for treatment. Patient #1 returned to the facility approximately 3 and a half hours later at 3:30 PM, was transferred to the Tyler I Unit and subsequently returned to the ER at approximately 5:00 PM that evening as a result of continuing to exhibit symptoms associated with Methadone overdose.

Per interview, at 12:53 PM on 1/25/12, the Tyler II Nurse Manager confirmed that Nurse #1 had continued to administer meds to patients after Methadone had gone missing and further stated that s/he had told Nurse #1 and all staff that medication administration had to be halted because they could not account for the missing Methadone.

2. Per record review staff failed to provide ongoing assessments of health status for Patient #1 who was readmitted to the facility on the afternoon of 1/20/12, following an acute care stay in the ICU (Intensive Care Unit) for monitoring and treatment of Methadone overdose. Per review of documentation completed at the hospital during Patient #1's acute care stay from 1/19/12 through 1/20/12, a nurse's note, dated 1/20/12 at 6:15 AM stated the patients's O2 (oxygen) saturation had dropped into the 80's when asleep requiring the use of oxygen to increase the saturation to a more normal level of 94-97%. The note also revealed that the patient had stated, "I have sleep apnea".

Although a history and physical had been conducted by medical staff upon the Patient's return to the facility on the evening of 1/20/12 , there was no evidence that facility staff were aware of the recent history of low O2 sats during sleep and the patient identified sleep apnea. The patient received 800 mg of Ibuprofen at 3:30 PM, (at which time his/her temperature was recorded as 100.1 degrees Fahrenheit), for complaints of a sore throat associated with a diagnosis of acute Uvulitis. Patient #1 was admitted to Tyler 1 at 6:40 PM and placed on observation status that included every 15 minute checks. The patient's temperature was taken on just two subsequent occasions and was recorded as 99.7 at 6:45 PM and 98.4 at 9:30 PM, respectively. Per review of the Nursing Observation Flow Sheet, dated 1/20/12, the patient was ambulating about the unit and talking with the nurse and other patients during the evening hours following admission, and was noted to be awake until approximately 12:30 AM. During the time period between 4:00 - 5:30 AM the patient was noted, every 15 minutes, to be yelling in sleep and snoring loudly. An Addendum for 1/21/12, documented by MHW (Mental Health Worker #2) on 1/24/12 at 2:20 AM, stated that, between 4:15 AM and 5:00 AM Patient #1 was doing " a lot of yelling in....sleep.. It sounded angry almost as if growling" and staff questioned if patient was having a nightmare. The record also stated that staff had attempted to awaken Patient #1 "numerous times as a means to get (patient) out of the dream or whatever was going on. This was done by calling (patient) name repeatedly with 1 response of "huh". Despite the previous recent history of low O2 sats during sleep, the patient's statement that s/he had sleep apnea, as well as the diagnosis of acute Uvulitis and elevated temperature on admission, and the noted change in Patient #1's condition exhibited by symptoms of intermittent yelling during sleep for a prolonged period, with difficulty arousing the patient, there was no evidence that nursing staff had conducted any health status assessment of the patient after 9:30 PM. During a subsequent visual check at 5:43 AM the patient was found unresponsive and without respirations, a Code Blue was called, CPR (Cardiopulmonary Resuscitation) was initiated and Patient #1 was subsequently transferred to the ER where s/he expired.

During separate interviews, conducted at 7:50 AM on 1/25/12 and 11:02 AM on 1/26/12, respectively, MHWs (Mental Health Workers) #1 and #2, both of whom had worked the Tyler I unit on the 11:00 PM - 7:00 AM shift on the night of 1/20/12 through 1/21/12 confirmed that Patient #1 had begun yelling in his/her sleep at approximately 4:00 AM and continued to do so until 5:35 AM. They stated that the night light was on in the patient's room providing enough light to determine that the patient's color remained good throughout the night. Patient #1 was described as yelling frequently and loud enough at times to awaken other patients. The MHWs stated that they had attempted to arouse the patient when s/he yelled and, although s/he would stop yelling the patient never awoke. MHW #2 stated that the patient "was obviously having a hard time." and s/he voiced concerns about Patient #1, to Nurse #3, the Charge Nurse on Tyler I during the 11:00 PM - 7:00 AM shift at the time. Nurse #3 told MHW #2 to just continue checking on the patient. At 5:35 AM Patient #1 was yelling again and was checked by both the MHWs. MHW #1 next conducted a visual check of Patient #1 approximately 8 minutes later at 5:43 AM and found the patient unresponsive.

Nurse #3, stated during interview at 11:02 AM on 1/25/12, that, although s/he does not routinely perform visual checks of patients during the night, s/he had visually checked on Patient #1 at least 4 times during the shift because of the concerns by MHWs regarding the patient's prolonged intermittent yelling. Nurse #3 stated that, although the patient's color was good, and the patient was moving about in bed, s/he "was screaming and hollering at times", and even woke up other patients s/he "was so loud". S/he further stated that s/he did not attempt to awaken Patient #1. Nurse #3 stated that, although s/he had received report that Patient #1 had been readmitted to the unit following acute care treatment for Methadone overdose, s/he had not been aware of Patient #1's elevated temperature or diagnosis of Uvulitis, and confirmed that s/he had not conducted any assessment of the patient's health status. Nurse #3 stated that s/he was called to Patient #1's room at approximately 5:43 AM and found the patient unresponsive and without respirations or pulse. S/he stated that CPR was initiated and a Code Blue was called. Patient #1 was subsequently transferred to the ER by ambulance at approximately 6:20 AM.
During interview, at 9:42 AM on the morning of 1/26/12, the Senior Vice President of Patient Care Services and CNO (Chief Nursing Officer) confirmed the lack of health status assessment for Patient #1 and stated that s/he would have expected nursing staff to conduct an assessment of the patient related to the patient's change in condition exhibited by prolonged yelling out and lack of response to staff attempts to arouse him/her during the night of 1/21/12.
3. Per record review, staff failed to evaluate Patient #20's health status, including Fall Risk, after the patient sustained a fall on 9/30/11. The patient, who utilized a cane to assist with ambulation, had a Fall Risk Assessment completed on admission, on 9/27/11, and was identified as low fall risk. A Shift Progress/Reassessment Note, dated 9/30/11 at 2:15 PM, stated; "difficulty getting around at times (fell onto both knees). Pt fell in community this am and was escorted to.......had room changed to.......Pt in wheelchair". There was no evidence that assessment of the patient's health status, including a re-assessment of fall risk status, had been conducted by nursing staff. The patient subsequently sustained a second fall, 3 days later on 10/3/11, with injury that required transfer to an acute care hospital for evaluation and treatment. During interview, at 10:51 AM on 3/21/11, the RN who was in the position of unit Charge Nurse on 9/27/11 at the time of the fall, stated that the fall was not witnessed and s/he did not document any information in the patient's medical record. The RN also confirmed that evaluation of the patient's health status and re-assessment of fall risk status had not been conducted after the fall on 9/30/11.
Refer also to A-0396

Based on staff interview and record review, the hospital failed to assure that nursing staff developed and kept current a nursing care plan to address each patient's needs for 6 of 30 patients in the applicable sample. (Patients # 26, 15, 16, 19, 20 & 5) Findings include:

1. Per record review on 3/20/12, Patient #15 had specific medical needs related to dental and foot pain. During an interview with the Clinical Manager and confirmed on 3/20/12 at 11:50 AM, staff failed to revise the nursing care plan for Patient #15 to include specific interventions, goals, and measurable objectives for foot and dental pain to assure that nursing addressed these needs.

2. Per record review on 3/19/12, Patient #16 had a specific medical need related to a gastrostomy tube (a surgical opening and tube to permit intake of nutritional fluids) and the 3/17/12 Admission Skin Assessment Form documented that Patient #16 had a gastrostomy tube. During an interview with the Clinical Manager and confirmed on 3/19/12 at 3:20 PM, staff failed to develop a nursing care plan for Patient # 16 to include specific interventions, and measurable goals/objectives related to the gastrostomy tube, to assure that nursing addressed this need.

3. Per record review on 3/20/12, the Initial Care Plan for Patient #19, who was admitted to the hospital after voicing suicidal ideation, failed to address this assessed need. Per the Comprehensive Intake Examination signed 3/11/12 at 0530, the patient "Repeatedly verbalized suicidal ideation". Although the RN Safety Assessment dated 3/10/12 at 9 PM included a safety plan stating "Pt. in LSA (low stimulation area) x 24 hr. with 1:1 staffing until TX (treatment) team re-assess.", a later RN Safety Assessment dated 3/11/12 at 0530, included no suicidal ideation care plan. The lack of a care plan to address this need was confirmed during interview with the Unit RN Manager at 11:30 AM on 3/20/12.

4. Per record review on 3/19/12, nursing staff failed to initiate a care plan to address interventions for Patient #5, who was admitted to the hospital for treatment of alcohol addiction compounded by a diagnosis of an "Eating Disorder". Since admission on 3/17/12, the patient had demonstrated behaviors associated with the eating disorder including purging through vomiting and limiting consumption of food. Per interview on the afternoon of 3/19/12, the Unit Manager confirmed that Patient #5 was demonstrating behaviors related to the eating disorder and a nursing care plan had not been initiated to direct staff with the management and approaches necessary to address this need.

5. Per record review, staff failed to revise Patient #20's care plan to reflect a fall and interventions implemented to reduce the risk of further falls. The patient, who utilized a cane to assist with ambulation, had a Fall Risk Assessment completed upon admission on 9/27/11. The patient was identified as low fall risk, and had a care plan initiated that included "Level 1: Universal (low) Fall Risk Prevention Strategies (instituted for everyone)". A Shift Progress/Reassessment Note, dated 9/30/11 at 2:15 PM, stated; "difficulty getting around at times (fell onto both knees). Pt fell in community this am and was escorted to.......had room changed to.......Pt in wheelchair". During interview, at 10:51 AM on 3/21/11, the RN who was in the position of unit Charge Nurse on 9/27/11 at the time of the fall, stated that although s/he had moved the patient to a room closer to the nursing station to monitor more closely and had provided a wheel chair for the patient to use for long distance locomotion, the care plan had not been updated to reflect these changes. The patient subsequently sustained a second fall, 3 days later on 10/3/11, with injury that required transfer to an acute care hospital for evaluation and treatment. Refer also to A-0395

6. a. Per record review on 3/20/12, nursing staff failed to develop a care plan related to Patient # 26 's refusal to allow hospital staff to administer her medications, which included psycho-active drugs. The patient was admitted to the hospital on 8/29/11 with a diagnosis of schizo-affective disorder and delusions. Beginning on 8/29/11 and for the first 72 days of his/her admission, the patient refused to allow staff to administer medications. On 11/11/11 a court order was obtained for the hospital staff to administer involuntary meds, and staff was then able to administer medications to the patient.
On 3/20/12 at 4 P.M. the acting Director of Nursing (DNS) confirmed that the facility failed to develop a care plan related to the patient's refusal to take his/her medications and the behaviors s/he manifested as a consequence of not taking them.

b. Per record review on 3/20/12, nursing staff failed to develop a care plan for hygiene issues manifested by Patient # 26's refusal to bathe, wash his/her hair, and refusal to allow staff to assist with incontinence care. The patient was unable to complete her own activities of daily living (ADL's) and refused to allow staff to assist him/her. This was confirmed on 3/20/12 at 3:50 P.M. by the acting DNS.

c. Per record review on 3/20/12, nursing staff failed to develop a care plan for weight loss for Patient # 26 although her history included a significant weight loss the months before entering the hospital and her poor nutritional intake while a hospital patient. This was confirmed by the acting DNS on 3/20/12 at 4 P.M.

d. Per record review on 3/20/12, for Patient # 26, although a diabetic/hypo/hyperglycemia care plan had been developed upon admission, nursing staff failed to revise the careplan when the patient refused to allow staff to check her finger stick blood sugar/accuchecks for glucose monitoring during her entire hospital stay (between 8/29/11 and 12/23/11). This was confirmed on 3/20/12 at 4 P.M. by the acting DNS.

Based on staff interview and record review nursing staff failed to administer medications in accordance with established policies and protocols and resulting in the potential for and actual negative outcome for 2 patients. (Patients #1 and #2). Findings include:

Per record review staff failed to follow the facility's policies which included: the policy for Medication Procurement, Distribution, Storage and Disposition, last revised in July 2011 and which stated: Medication Storage and Disposition; When a medication is delivered to a unit it shall be locked in the designated location in the medication room unless it is to be administered immediately.....All Controlled Substances stored on the unit shall be secured and locked inside the medication cart drawer or a cabinet; the policy titled Administration and Scheduled Time of Medication, last revised and approved in July of 2011, which stated: III. Verifications, Education and Discussion: "Before administering medication staff will: Verify that there is no contraindication for administering the medication"; and the protocol for responding to missing medication, titled Safety Searches - Unit Lock-down for Contraband, dated June 2006, which stated; "All medication passes are to be halted and no medication may be given until cleared with the Unit Manager or Supervisor".

Patient #1, who was admitted to the Tyler 2 Unit on 1/18/12 for treatment of suicidal ideation and alcohol detox., was able to obtain and ingest the Methadone (opiate) prescribed for Patient #2 during a medication (med) pass on the morning of 1/19/12. Per interview, at 3:20 PM on 1/24/12, Nurse #1, who was responsible for med pass for all patients on Tyler 2 on 1/19/12, stated that s/he was inside the med room that morning with the bottom half of the Dutch style door to the room closed. Although the facility's policy for storage of medication specifies that medication delivered to a unit shall be locked in the designated location in the med room unless it is to be administered immediately, and all Controlled Substances, like Methadone, stored on the unit shall be secured and locked inside the medication cart drawer or a cabinet, Nurse #1 stated that s/he had prepared medications for several patients, placed the meds in individual plastic med cups, identified by patient name, and lined the cups up on the top of the med cart which was located next to the door and reachable by someone standing outside the door. Nurse #1 stated that Patient #1 presented at the med room door for his/her medication at approximately 9:00 or 9:30 AM that day. S/he stated that the patient, who was on an alcohol detox program, received 75 mg of Librium (benzodiazipine used to relieve anxiety and control agitation caused by alcohol withdrawal) at that time but continued to stand at the door, leaning on the shelf of the half door and repeatedly asking for Ritalin, for which there was no physician order, while other patients lined up in the hallway awaiting their turns for med administration. Nurse #1 stated that s/he had turned his/her head away from the Patient #1 for a short period just once during the exchange. Patient #1 left the area of the med room and the nurse continued to administer meds to other patients. Nurse #1 stated it was within 15 minutes of the exchange with Patient #1 that Patient #2 presented to the med room door asking for their daily maintenance dose of 110 mg of Methadone and the nurse was not able to find the pre-poured medication. S/he stated s/he had previously prepared the (2) 40 mg wafers and (6) 5 mg tablets totaling the 110 mg dose, placed them in a plastic med cup with another plastic med cup covering it and placed it on top of the med cart prior to the exchange with Patient #1. Nurse #1 stated that s/he alerted other staff and the Pharmacy that the Methadone was missing. S/he stated that, with the assistance of a pharmacy technician, they searched, unsuccessfully, throughout the med room for the Methadone. The protocol for Safety Searches - Unit Lock down for Contraband was implemented immediately following the identification of missing Methadone; and patients were gathered in the community area.. Nurse #1 stated that, during this time, although s/he had not consulted Patient #2's attending physician, s/he did speak with Pharmacist #1 about providing the maintenance dose of Methadone to Patient #2 who had still not received the medication and the Pharmacist told Nurse #1 that Patient #2 needed the medication. Despite the fact that administration of Methadone to Patient #2 was contraindicated because staff had not been able to account for the missing Methadone, and it was a violation of the protocol that stated to halt all medication administration, and, finally, without consulting the attending physician, Nurse #1 confirmed that s/he administered 110 mg of Methadone to Patient #2 (at 9:30 AM according to the Medication Administration Record). In addition Nurse #1 stated that s/he continued to administer medication to the 3 or 4 patients that had still not received their scheduled medications.

Nurse #2 stated during interview at 3:45 PM on 1/24/12, that while all patients were gathered in the community area of the unit, Patient #1 approached him/her and admitted that s/he had found a white pill (a 40 mg wafer of Methadone) on the floor of the bathroom that morning and had ingested it. A body search was then conducted on Patient #1 and during the contraband search of Patient #1's room s/he revealed a 5 mg tablet of Methadone that had been taped to the underside of a drawer. Patient #1 was placed on 1:1 observation status and after beginning to exhibit symptoms of Methadone overdose, including slurred speech, decreased respirations, increasing lethargy and constricted pupils, s/he was transferred, at 11:55 AM, to the ER (Emergency Room) for treatment. Patient #1 returned to the facility approximately 3 and a half hours later at 3:30 PM, was transferred to the Tyler I Unit and subsequently returned to the ER at approximately 5:00 PM that evening as a result of continuing to exhibit symptoms associated with Methadone overdose.

Per interview, at 12:53 PM on 1/25/12, the Tyler II Nurse Manager confirmed that Nurse #1 had continued to administer meds to patients after Methadone had gone missing and further stated that s/he had told Nurse #1 and all staff that medication administration had to be halted because they could not account for the missing Methadone.

Based on staff interviews and record review the Condition of Pharmacy Services is not met as evidenced by the failure to ensure safe and secure storage of all drugs in accordance with established policies and protocols, to prevent access by patients, and resulting in a negative patient outcome. In addition there was a failure to assure that pharmacy staff provided information to nursing staff in a manner that would promote safe medication use in accordance with established policies and protocols.






Refer to tag A-0502

Based on staff interview and record review the Pharmacy Department failed to ensure that all Controlled drugs were securely stored in a manner that prevented unauthorized access by patients, and failed to assure that medications were administered in a manner consistent with facility Policies and Procedures. Findings include:

Per record review staff failed to follow the facility's policies which included: the policy for Medication Procurement, Distribution, Storage and Disposition, last revised in July 2011 and which stated: Medication Storage and Disposition; When a medication is delivered to a unit it shall be locked in the designated location in the medication room unless it is to be administered immediately.....All Controlled Substances stored on the unit shall be secured and locked inside the medication cart drawer or a cabinet; the policy titled Administration and Scheduled Time of Medication, last revised and approved in July of 2011, which stated: III. Verifications, Education and Discussion: "Before administering medication staff will: Verify that there is no contraindication for administering the medication"; and the protocol for responding to missing medication, titled Safety Searches - Unit Lock-down for Contraband, dated June 2006, which stated; "All medication passes are to be halted and no medication may be given until cleared with the Unit Manager or Supervisor".

Patient #1, who was admitted to the Tyler 2 Unit on 1/18/12 for treatment of suicidal ideation and alcohol detox., was able to obtain and ingest the Methadone (opiate) prescribed for Patient #2 during a medication (med) pass on the morning of 1/19/12. Per interview, at 3:20 PM on 1/24/12, Nurse #1, who was responsible for med pass for all patients on Tyler 2 on 1/19/12, stated that s/he was inside the med room that morning with the bottom half of the Dutch style door to the room closed. Although the facility's policy for storage of medication specifies that medication delivered to a unit shall be locked in the designated location in the med room unless it is to be administered immediately Nurse #1 stated that s/he had prepared medications for several patients, placed the meds in individual plastic med cups, identified by patient name, and lined the cups up on the top of the med cart which was located next to the door and reachable by someone standing outside the door. Nurse #1 stated that Patient #1 presented at the med room door for his/her medication at approximately 9:00 or 9:30 AM that day. S/he stated that the patient, who was on an alcohol detox program, received 75 mg of Librium (benzodiazipine used to relieve anxiety and control agitation caused by alcohol withdrawal) at that time but continued to stand at the door, leaning on the shelf of the half door and repeatedly asking for Ritalin, for which there was no physician order, while other patients lined up in the hallway awaiting their turns for med administration. Nurse #1 stated that s/he had turned his/her head away from the Patient #1 for a short period just once during the exchange. Patient #1 left the area of the med room and the nurse continued to administer meds to other patients. Nurse #1 stated it was within 15 minutes of the exchange with Patient #1 that Patient #2 presented to the med room door asking for their daily maintenance dose of 110 mg of Methadone and the nurse was not able to find the pre-poured medication. S/he stated s/he had previously prepared the (2) 40 mg wafers and (6) 5 mg tablets totaling the 110 mg dose, placed them in a plastic med cup with another plastic med cup covering it and placed it on top of the med cart prior to the exchange with Patient #1. Nurse #1 stated that s/he alerted other staff and the Pharmacy that the Methadone was missing. S/he stated that, with the assistance of a pharmacy technician, they searched, unsuccessfully, throughout the med room for the Methadone. The protocol for Safety Searches - Unit Lock down for Contraband was implemented immediately following the identification of missing Methadone; and patients were gathered in the community area.. Nurse #1 stated that, during this time, although s/he had not consulted Patient #2's attending physician, s/he did speak with Pharmacist #1 about providing the maintenance dose of Methadone to Patient #2 who had still not received the medication and the Pharmacist told Nurse #1 that Patient #2 needed the medication. Despite the fact that administration of Methadone to Patient #2 was contraindicated because staff had not been able to account for the missing Methadone, and it was a violation of the protocol that stated to halt all medication administration, and, finally, without consulting the attending physician, Nurse #1 confirmed that s/he administered 110 mg of Methadone to Patient #2 (at 9:30 AM according to the Medication Administration Record). In addition Nurse #1 stated that s/he continued to administer medication to the 3 or 4 patients that had still not received their scheduled medications.

Nurse #2 stated, during interview at 3:45 PM on 1/24/12, that while all patients were gathered in the community area of the unit, Patient #1 approached him/her and admitted that s/he had found a white pill (a 40 mg wafer of Methadone) on the floor of the bathroom that morning and had ingested it. A body search was then conducted on Patient #1 and during the contraband search of Patient #1's room s/he revealed a 5 mg tablet of Methadone that had been taped to the underside of a drawer. Patient #1 was placed on 1:1 observation status and after beginning to exhibit symptoms of Methadone overdose, including slurred speech, decreased respirations, increasing lethargy and constricted pupils, s/he was transferred, at 11:55 AM, to the ER (Emergency Room) for treatment. Patient #1 returned to the facility approximately 3 and a half hours later at 3:30 PM, was transferred to the Tyler I Unit and subsequently returned to the ER at approximately 5:00 PM that evening as a result of continuing to exhibit symptoms associated with Methadone overdose.

During interview, at 10:14 AM on 1/25/12, Pharmacist #1 confirmed that Nurse #1 had contacted him/her on the morning of 1/19/12 to report that Methadone was missing. The Pharmacist stated that during the conversation the question came up about giving Patient #2 their prescribed Methadone. S/he stated that Nurse #1 had expressed that s/he was sure Patient #2 had not taken the Methadone and the Pharmacist told Nurse #1 that s/he would give the Methadone if positive Patient #2 hadn't had it.

The Director of Pharmacy Services agreed, during interview at 9:50 AM on 1/25/12, that there was a potential for Methadone overdose to occur if a patient receiving a daily maintenance dose of 110 mg were given more than the maintenance dose. During a subsequent interview, at 9:55 AM on 1/26/12, the Director of Pharmacy Services agreed that administration of medication should be halted, in accordance with the facility's established protocol for Safety Searches - Unit Lock-down for Contraband during any event when staff are not able to account for missing patient medications. S/he further agreed that response by pharmacy staff to questions posed regarding medication administration during an event requiring a unit lock-down should reflect the directives in the protocol.

Based on observations, staff interviews and log and policy/procedure reviews, the Director of Food Services (DFS) failed to assure that the hospital kitchen and food storage areas were maintained in a sanitary manner, in accordance with accepted safe food handling practices.
Findings include:

During the initial tour of the facility kitchen on 3/19/12 at 1:45 P.M., accompanied by the DFS, the following observations were made:

1. In the kitchen 3 bay pot sink, the sanitizer level was measured at less than the recommended level of 150 parts per million (PPM) for proper sanitization of dishware. The sink was in use at the time of the observation and levels were tested by both kitchen staff and the FSD
2. In the dry storage room, a cardboard box labeled "pinto beans" was observed uncovered, open to the air. Facility policy states that all bulk dry goods are to be in a metal or plastic lidded container.
3. A window screen, glass and sill directly above a food preparation table was soiled with dead insects, dust and debris. The window was open and the wind was blowing into the kitchen at the time of the observation.
4. A table-mounted manual can opener, including the base and the metal puncture blade, was heavily soiled with a dark colored viscous substance.
5. A spider web, approximately 1 foot in length and visible dust debris were observed directly over the door between the serving line and the main kitchen area.
6. Two metal racks where pots and pans were stored were visibly soiled with dust.

All of the above observations were confirmed by the FSD at the time of the observations.

Per review of freezer logs on 3/20/12 at 1:30 P.M., the potato freezer recorded temperatures were in excess of zero degrees Fahrenheit (F). Facility policy states that freezer temperature must be 0 degrees or below. Staff recorded temperatures twice daily, and between 12/31/11 - 1/20/12, temperatures exceeded 0 degrees on 36 occasions. During interview, the FSD confirmed these observations and stated that staff were expected to notify management of temperatures that were outside normal limits and in this case, had failed to do so.

Per observations on 3/21/12 between 10:30 and 10:50 A.M., patient refrigerators on all units exceeded recommended temperatures. Per facility policy, perishable foods are to be kept at no more than 40 degrees F. Recorded temperatures for March 2012 exceeded 40 F 6 times on Osgood 1; 22 times on Tyler 1; 1 time on Tyler 2; 6 times on Tyler 3 and 4 times on Tyler 4. During an interview on 3/21/12 at 10:55 A.M., the FSD stated that housekeeping was responsible for taking temperatures for the unit refrigerators. Unit staff, with the exception of Tyler 3, stated that night shift nursing staff was responsible for the temperature recording. Additionally, the form used to record the temperatures indicated that temperatures were not to exceed 46 degrees F which is contrary to both facility policy and accepted safe food practice.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that identified physician and nursing interventions that were individualized and specific to the treatment needs for 8 of 8 active sample patients (A7, A14, B7, C7, D2, D13, E3 and E6). Instead, the MTPs included interventions which were routine, generic discipline functions that lacked focus for treatment. This failure results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

The sample patients' MTPs included the notation: "Who are the members of your team and how will we help you achieve your goals..." The following generic interventions were listed:

1. Patient A7 (MTP dated 3/17/12)

"[Physician] will talk with you about appropriate medications, educate you on the long-term physiological effects of substance abuse/dependence, assess other psychiatric symptoms that may be impacting your recovery and will monitor your medical safety..." "[Nursing] will monitor your detox symptoms and any acute medical issues you may have, support you in participating in groups and activities."

2. Patient A14 (MTP dated 3/16/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

3. Patient B7 (MTP dated 3/14/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

4. Patient C7 (MTP dated 3/3/12)

"Psychiatrist] will continue to evaluate for possible adjustments or changes in medications." "[Nursing] will administer medications, assess for effectiveness, observe for side effects, review safety assignments for clinical effectiveness and assist the patient with remaining safe and provide assignments to do so as necessary."

5. Patient D2 (MTP dated 1/20/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

6. Patient D13 (MTP dated 3/5/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

7. Patient E3 (MTP dated 2/23/12)

"[Psychiatrist] will continue to evaluate for possible adjustments or changes to medications."
"[Nursing] will administer medications, assess for effectiveness, and observe for side effects."

8. Patient E6 (MTP dated 3/11/12)

"[Psychiatrist] will continue to evaluate for possible adjustments or changes to medications."
"[Nursing] will administer medications, assess for effectiveness, and observe for side effects."

B. Staff Interview

During an interview on 3/20/12 at 1:30p.m., the Medical Director confirmed that the treatment plans were "boilerplate" and non-specific.

Based on record review and interview, the Medical Director failed to ensure that the Master Treatment Plans for 8 of 8 active sample patients (A7, A14, B7, C7, D2, D13, E3 and E6) included individualized interventions. The interventions were non-specific and similar on all treatment plans regardless of the patients' problems. This failure results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

Review of the sample patients' MTPs included the notation: "Who are the members of your team and how will we help you achieve your goals..." The following generic interventions were listed:

1. Patient A7 (MTP dated 3/17/12)

"[Physician] will talk with you about appropriate medications, educate you on the long-term physiological effects of substance abuse/dependence, assess other psychiatric symptoms that may be impacting your recovery and will monitor your medical safety..." "[Nursing] will monitor your detox symptoms and any acute medical issues you may have, support you in participating in groups and activities."

2. Patient A14 (MTP dated 3/16/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

3. Patient B7 (MTP dated 3/14/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

4. Patient C7 (MTP dated 3/3/12)

"Psychiatrist] will continue to evaluate for possible adjustments or changes in medications." "[Nursing] will administer medications, assess for effectiveness, observe for side effects, review safety assignments for clinical effectiveness and assist the patient with remaining safe and provide assignments to do so as necessary."

5. Patient D2 (MTP dated 1/20/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

6. Patient D13 (MTP dated 3/5/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

7. Patient E3 (MTP dated 2/23/12)

"[Psychiatrist] will continue to evaluate for possible adjustments or changes to medications."
"[Nursing] will administer medications, assess for effectiveness, and observe for side effects."

8. Patient E6 (MTP dated 3/11/12)

"[Psychiatrist] will continue to evaluate for possible adjustments or changes to medications."
"[Nursing] will administer medications, assess for effectiveness, and observe for side effects."

B. Staff Interview

During an interview on 3/20/12 at 1:30p.m., the Medical Director confirmed that the treatment plans were "boilerplate" and non-specific.

Based on interview and record review, the Interim Director of Nursing failed to ensure that the Master Treatment Plans for 8 of 8 active sample patients (A7, A14, B7, C7, D2, D13, E3 and E6) included specific nursing interventions. The listed nursing interventions were generic nursing activities. This deficiency can result in the lack of an integrated focus for patient treatment and fragmented nursing care for patients.

Findings include:

A. Record Review

1. Patient A7: The Master Treatment Plan of 3/17/12 included the following generic nursing interventions: "nursing staff will complete a Medical Nursing Care Plan if indicated and monitor symptoms as appropriate"; "nursing staff will encourage your participation in group and unit activities" and "nursing staff will monitor detox symptoms and any acute medical issues you may have, support you in participating in groups and activities."

2. Patient A14: The Master Treatment Plan of 3/16/12 included the following generic nursing interventions: "nursing staff will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medication."

3. Patient B7: The Master Treatment Plan of 3/14/12 included the following generic nursing interventions: "nursing staff will monitor your detox symptoms and any acute medical issues you may have, support you in participating in groups and activities" and "nursing staff will complete a Medical Nursing Care Plan if indicated and monitor your symptoms as appropriate."

4. Patient C7: The Master Treatment Plan of 3/3/12 included the following generic nursing interventions: "nursing will administer medications, assess for side effects, review safety assignments for clinical effectiveness, and assist the patient with remaining safe and provide assignments to do so as necessary" and "nursing will encourage appropriate social interactions in the milieu. During 1:1 time will help pt. identify resources and coping skills."

5. Patient D2 (MTP dated 1/20/12)


"[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

6. Patient D13 (MTP dated 3/5/12)

"[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

7. Patient E3 (MTP dated 2/23/12)

"[Nursing] will administer medications, assess for effectiveness, and observe for side effects."

8. Patient E6 (MTP dated 3/11/12)

"[Nursing] will administer medications, assess for effectiveness, and observe for side effects."

B. Staff Interviews

During an interview on 3/20/12 at 2:30p.m., the Interim Director of Nursing and Clinical Manager agreed that nursing interventions were written similarly on all Master Treatment Plans.