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Based on record review and interview, the psychiatric hospital failed to provide care in a safe setting. The deficient practice is evidenced by failure to monitor the patient according to the ordered level of observation in 1 (#3) of 3 (#1-#3) reviewed medical records.
Findings:

Review of the medical record for Patient #3 revealed admission on 04/28/2024 with a diagnosis of bipolar disorder.

Review of the nursing notes from 04/29/2024 at 11:40 a.m. revealed "Patient grabbed housekeeping penis while mopping. S4MD wants to give PRN." Further review revealed an additional nursing note at 11:46 a.m., "Room was changed and placed on 1 to 1. Review of the evening shift notes and observation sheets failed to reveal documentation the patient was on one to one observation.

Review of the physician's orders revealed a verbal order initiated on 04/29/2024 at 12:05 p.m. for 1 to 1 observation.

Review of the psychiatrist note from 04/29/2024 at 1:29 p.m. revealed in part, "The staff has reported that the patient is sexually inappropriate. He was touching people on the unit. He was placed on 1 on 1 due to sexually inappropriate behavior."

Review of the Nursing Assignment Sheets for 04/29/2024 for the day and evening shift revealed the patient was on line of sight observation.

In interview on 05/08/2024 at 2:02 p.m., S3RN verified there was no documentation Patient #3 was observed 1 to 1 on the evening of 04/29/2024 as ordered by the physician.

Based on record review and interview, the nursing staff failed to assess the care needs and health status of each patient on admission. The deficient practice is evidenced by failure to complete the Nursing Admission Assessment in 1 (#2) of 3 (#1-#3) reviewed medical records.
Findings:

Review of Policy PC81, "Plan of Care- Protocol for the Use of Multidisciplinary Format," reviewed 08/2023, revealed in part, "Nursing will complete an admission Assessment within eight (8) hours of admission . . . . The Charge Nurse or designee will update the Master Problem List by adding new problems, closing resolved problems and entering the appropriate status code. . . . All unit staff should be apprised of revisions and review the plan of care prior to making a care intervention with the patient."

Review of the Nursing Admission Assessment initiated on 04/05/2024 at 5:40 p.m. revealed the nurse documented in several places "refuses-sleepy," and "too sleepy assess." Further review revealed the assessment was never completed and never signed and dated by the nurse attempting the assessment.

In interview on 05/08/2024 at 2:25 p.m., S2RN verified the assessment was started but not completed because the patient could not cooperate. S2RN verified the nurse failed to complete the assessment at a later time when the patient was more cooperative.

Based on record review and interview, the nursing staff failed to update the plan of care after a significant event. The deficient practice is evidenced by failure to update the nursing plan of care after sexually inappropriate behavior was noted for 1 (#3) for 3 (#1-#3) reviewed medical records.
Findings:

Review of Policy PC81, "Plan of Care- Protocol for the Use of Multidisciplinary Format," reviewed 08/2023, revealed in part, "Nursing will complete an admission Assessment within eight (8) hours of admission . . . . The Charge Nurse of designee will update the Master Problem List by adding new problems, closing resolved problems and entering the appropriate status code. . . . All unit staff should be apprised of revisions and review the plan of care prior to making a care intervention with the patient."

Review of the medical record for Patient #3 revealed admission on 04/28/2024 with a diagnosis of bipolar disorder.

Review of the nursing notes from 04/29/2024 at 11:40 a.m., revealed the patient had inappropriately grabbed housekeeping.

Review of the psychiatrist note from 04/29/2024 at 1:29 p.m. revealed in part, "The staff has reported that the patient is sexually inappropriate. He was touching people on the unit. He was placed on 1 on 1 due to sexually inappropriate behavior."

Review of the plan of care revealed the plan was not updated to include sexually inappropriate behavior.

In interview on 05/08/2024 at 2:19 p.m., S2RN verified the plan of care was not updated to address the sexually inappropriate behavior.

Based on record review and interview, the nursing staff failed to follow hospital policy and standard of care for medication administration. The deficient practice is evidenced by failure to follow up after administration of PRN medication for effectiveness in 2 (#2, #3) of 3 (#1-#3) reviewed medical records.
Findings:

Review of Policy MM24, "Medication Administration," reviewed 08/2023. revealed in part, "'PRN' medications administered are qualified by designating the times of administration and parameters, i.e. patient's blood sugar, blood pressure. . . . Each dose of medication administered is properly recorded in the patient's medical record on the Medication Administration Record. The nurse marks through the medication and initial the block next to the appropriate date and time on the MAR when medication is given. The nurse circles the time block if the patient refuses the medication or if it is not given. The nurse documents refusals and all relevant information on the back of the MAR."

Patient #2
Review of the physician orders for Patient #2 revealed an order initiated on 04/05/2024 at 6:00 p.m. for Zofran 4 milligrams by mouth every 6 hours as needed for nausea and/or vomiting.

Review of the Medication Administration Record revealed the medication was administered on 04/09/2024 at 8:25 p.m. Further review of the medication administration record and the nurses notes failed to reveal the nurse followed up for effectiveness.

In interview on 05/08/2024 at 2:26 p.m., S2RN verified the nursing staff did not follow up after administering the PRN medication. S2RN verified the nursing staff should have documented the reason it was given and the follow-up for effectiveness on the back of the medication administration sheet.

Patient #3
Review of the physician orders for Patient #3 revealed an order initiated on 04/28/2024 at 1:55 p.m. for Haldol 5 milligrams PO/IM PRN every 6 hours as needed for psychosis, Ativan 2 milligrams PO/IM PRN every 6 hours as needed for anxiety, and Benadryl 50 milligrams PO/IM PRN every 6 hours as needed for anxiety.

Review of the nursing notes for 04/29/2024 at 11:40 a.m. revealed an incident where the patient inappropriately grabbed housekeeping and the psychiatrist "wants to give PRN."

Review of the psychiatrist note from 04/29/2024 at 1:29 p.m., revealed in part, "He was given a B52."

Review of the MAR for 04/29/2024 revealed no documentation the medication was given.

Further review of the MAR revealed the three medications were given by injection on 04/28/2024 at 2:55 p.m., 05/01/2024 at 6:55 p.m. 05/03/2024 at 11:20 a.m. and 5:34 p.m. with no documentation of the site or if the medication was effective.

In interview on 05/08/2024 at 2:19 p.m., S2RN verified the nursing failed to document the medication administration on the medication administration record when given on 04/29/2024 and did not document a follow-up for effectiveness on 04/28/2024, 05/01/2024, and 05/03/2024.