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Based on observation and interview, the hospital failed to ensure patients at risk for harm to self or others were provided care in a safe setting. This deficient practice is evidenced by failure to ensure the patients' physical environment was free of safety risks and did not afford opportunities for self -injury/harm to others.

Findings:

On 11/5/19 from 3:35 p.m. - 3:55 p.m. an observation was made of the patient care areas and inpatient rooms. The following safety risks were observed in the patient care environment:

a. Bathroom in Room "a". The water shut off valve plumbing was exposed and could be used for a potential anchor point for ligature.

b. Bathroom in Room "b". The base of the toilet was exposed revealing a gap between the toilet and the wall leaving an opening that could be used for a potential anchor point for ligature.

The above referenced safety risk findings were confirmed by S2DON who was present during the observation.

Based on observation, record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services. The RN who was responsible for supervision and evaluation of the nursing care for each patient failed to ensure that care was provided in accordance with accepted standards of nursing practice and hospital policy relative to admission orders. Medication orders, laboratory testing, and diet orders upon admission were written and initiated by nursing staff without the prior ordering and approval of a physician/LIP for 1 of 1 (#8) patient sampled for review of admission orders at the hospital's offsite location. 4 of 4 nurses (S5LPN, S3RN, S4RN, and S6LPN) and 1 of 1 psychiatrist (S7Psych) interviewed indicated that physicians were not routinely called to review and provide verbal authorization for admission orders that were written by nursing staff prior to the nurses implementing the orders. (See findings in tag A-0395).

Based on record reviews and interviews, the RN who was responsible for supervision and evaluation of the nursing care for each patient failed to ensure that care was provided in accordance with accepted standards of nursing practice and hospital policy relative to admission orders. This deficient practice was evidenced by:

1) failure to ensure medication orders, laboratory testing, and diet orders upon admission were not written and initiated by nursing staff without the prior ordering and approval of a physician/LIP for 1 of 1 (#8) patient sampled for review of admission orders at the hospital's offsite location. 4 of 4 nurses (S5LPN, S3RN, S4RN, and S6LPN) and 1 of 1 psychiatrist (S7Psych) interviewed indicated that physicians were not routinely called to review and provide verbal authorization for admission orders that were written by nursing staff prior to the nurses implementing the orders. (See findings in tag A-0395); and

2) failure of the RN to ensure patient vital signs were taken and recorded every 4 hours, for 24 hours, as ordered for 1 (#9) of 5 (#7-#11) sampled patients at the hospital's offsite location who were reviewed for vital sign monitoring from a total patient sample of 11 (#1- #11).

Findings:

1) Failure of the RN to obtain patient admission orders from a physician/licensed independent practitioner.

Review of the Statutory Definition for RN Scope of Practice R.S. 37:913 revealed the following, in part: (13) "Practice of Nursing" means the performance, with or without compensation, by an individual licensed by the board as a registered nurse, of functions requiring specialized knowledge and skills derived from the biological, physical, and behavioral sciences. The practice of nursing or registered nursing shall not be deemed to include acts of medical diagnosis or medical prescriptions of therapeutic or corrective nature.

Review of the hospital policy titled," Medications", Policy Number: MM-01, effective date: 1/11/16, last revised 10/1/18, revealed in part: Policy: The hospital will ensure all medications related to the patients' inpatient stay are ordered, dispensed, labeled, stored, transcribed, administered, and documented in the medical record in accordance with Federal and State Law and industry best practices.

- A medication order is a prescription given by a licensed practitioner who is permitted to prescribe medications under the laws of the State. Only a member of the medical staff who is licensed to prescribe is authorized to prescribe medications to patients in the hospital.

- Procedure: Physician/LIP: Writes medication order. Guidelines: 3. The nurse will read back verbal order and physician/LIP will confirm - then nurse will document RBVO (read back verbalized order).

- Nurse/Pharmacist: 4. Documents all medication orders in Physician/LIP order sheet in chronological order. Dates, times, and signs physician's name and person accepting the order. Reads back all verbal orders (RBVO) for clarification and accuracy.

Review of Patient #8's medical record revealed an admission date of 8/20/19 at 4:00 p.m. with an admission diagnosis of acute psychosis and co-morbid diagnoses of Depression, Diabetes Mellitus, Hypothyroidism, Hypertension, Gout, and Seizures. Further review revealed the patient's legal status was PEC due to having been labile, tearful, being positive for hallucinations, paranoia, and violent outbursts. The patient described as being gravely disabled and unable to seek voluntary admission.

Review of the hospital's document titled, "Admit Orders/Initial Plan of Care", revealed the orders were pre-printed sheets with boxes next to various orders that could be "checked" to indicate an order had been selected. Further review revealed the selections included orders for labs, diets, precautions, observation levels, drug levels, activity levels, and vital sign frequency. Additional review revealed a section titled, "Medications on Admit" with a check box next to it indicating, "Medications were reconciled with MD on Admission Medication Reconciliation Order". There was a section at the bottom of the orders with "Nurse Receiving Orders/RBVO" pre-printed with a place for the nurse to sign his/her name and a place for the date and time.

Review of Patient #8's "Physician Order/Admission Medication Reconciliation" form revealed the information source for the medication reconciliation was the referring hospital. The form had columns with the following headings: Medication, Dose, Route, Frequency, Last Dose, Order (with a box to check marked "Continue" or "Stop"), and the indication for the medication.

Patient #8's medication list included the following medications which had been checked as "Continue":
Metformin 500 mg x 2 po TID with meals - Diabetes
Synthroid 50 mcg po before breakfast - Hypothyroidism
Nifedipine ER 30 mg po before breakfast - Hypertension
Allopurinol 100 mg po daily - Gout
Ferrous Sulfate 325 mg po daily - Supplement
Lisinopril 20 mg po daily - Hypertension
Provastatin 40 mg po q hs - Hyperlipidemia
Vimpat 200 mg po BID - Seizures
Keppra 500 mg po BID - Seizures
Sildenafil 20 mg po TID - Vasodilator
Zofran HLC 4 mg po q 6 hours PRN - Nausea
Colace 100 mg po daily PRN - Constipation
Lexapro 10 mg po daily - Depression
Seroquel 25 mg po q hs Antipsychotic

Further review revealed checked boxes for the following PRN medications: Maalox 30 ml po PRN 4 hours PRN GI upset, Tylenol 325 mg po PRN q 4 hours for pain, Milk of Magnesia 30 ml po PRN q day for constipation. The form had been completed by S5LPN as a RBVO per S7Psych on 8/20/19 at 4:00 p.m. The order had been signed by S7Psych on 8/22/19 at 12:30 p.m. (2 days after admission).

In an interview on 11/5/19 at 9:33 a.m. with S5LPN, she confirmed, after review of Patient #8's medical record, she had transcribed the patient's medications onto the medication reconciliation/order form when the patient was admitted. S5LPN indicated she had reviewed the patient's transfer orders prior to the patient's arrival and had read over the patient's transfer paperwork in order to review the medications the patient was on, the frequency, the dosage, and the route. S5LPN explained she transcribed that information onto the patient's medication reconciliation/order form. S5LPN reported the medication reconciliation/order form was then sent to the pharmacy as the patient's medication orders and the pharmacy sent the patient's printed medication administration record. S5LPN explained the medication orders were written as verbal orders and the physician/LIP was not called to review each of the medications prior to them being ordered. S5LPN reported the physician/LIP signed the order when they come in to assess the patient the same day or the next morning.

S5LPN indicated the admit nurse ordered the patient's diet. She explained the nurse reviewed the patient's medications and for example, if the patient is Diabetic a no concentrated sweets diet is chosen on patient's admit orders and if they are on cardiac medications a low sodium/no added salt diet is chosen on the patient's admit orders. S5LPN further explained when the dietician came to assess the patient she may change the patient's diet based on her assessment.

S5LPN reported at times the admitting nurse chooses the patient's labs and enters them on the patient's admit orders. S5LPN further reported at times the admitting nurse doesn't order the labs because it depends on what physician/LIP is on at the time of the patient's admit. She explained some physicians/LIPs don't mind you ordering the patient's labs and some like to order their own patient labs.

In an interview on 11/5/19 at 8:24 a.m. with S3RN, she indicated patient information for admission was obtained from the paperwork that accompanied the patient from the transferring facility. She reported the admitting nurse transcribed the patient's medications from the medication list that came in with the patient on admission. S3RN indicated she did not call the admitting physician to review each of the patient's medications when transcribing the medications unless she had questions about the medications. She confirmed the medication list was faxed to the pharmacy for initiation of the medications after the admitting nurse had transcribed them from the transferring facility information. S3RN indicated the admitting physician reviewed the medication list later when they came in assess the patient, either the same day of admission or within 24 hours of the patient's admit.

In an interview on 11/5/19 at 8:57 a.m. with S7Psych, she reported the admitting nurse gathered the patient's medication information from the medication reconciliation form from wherever they were being admitted from. S7Psych indicated the nursing staff may call the patient's routine pharmacy to get clarification for the medications on the list and when she or the NP came in to assess the patient they would review the medication list as it was written up, perform the patient evaluation, and go from there deciding which medications would be continued, discontinued, and if any dose changes needed to be made. She reported the nursing staff does not typically call and review the patient information with her for patient admit, they use information that is provided with the patient upon transfer. S7Psych indicated the patients may come in overnight, but they assess the patient within 24 hours of their admission into the hospital and they would review the orders at that time.

In an interview on 11/5/19 at 10:51 a.m. with S4RN, she reported patient admit orders were written as a RBVO and the physician/LIP came in later, usually within 24 hours of admit, to review the admit information and co-sign the order. S4RN explained the patient's medications were transcribed to the medication reconciliation/order form from the medication list from the previous hospital or home medication list as admit medication orders. S4RN indicated they faxed the order to pharmacy. She also reported the nurses ordered the patient's diet based upon what the patient's diet was at the transferring facility.

In an interview on 11/5/19 at 1:06 p.m. with S6LPN, she indicated the medication information used to write admission medication orders was usually obtained from the facility the patients were coming from, from the patient, or the patient's family. She explained the admitting nurse may also call the patient's pharmacy. She confirmed the nurse transcribing the medication reconciliation started the patients on their previous medications at their previous dose and frequency until the physician/LIP saw them. She reported nurses chose the patient's diet orders and medication orders based on information in the admission packet. She explained the patient's admit orders were written as a read back verbal order, without calling and reviewing the orders with the physician/LIP. She reported when the physician/LIP came in they signed the orders and if they wanted to make medication changes that was the time they would make changes.

S6LPN indicated the RN ordered patient levels of observation and precautions when the patient was admitted. She explained if the patient had a history of attacking/assaulting behaviors they would be placed on homicide/assault precautions by the admitting nurse. If the patients had attempted suicide or had expressed suicidal ideations they were placed on suicide precautions by the admitting nurse. She reported the admitting RN ordered fall precautions on all patients. S6LPN further reported all patients were ordered to be on every 15 minute level of observation by the admitting RN unless they needed to be placed on 1:1 level of observation.

S6LPN indicated starting patients on medications without calling the physician/LIP had made her uncomfortable because that made her a prescriber. She said she had voiced her concerns about the admit process and she was told, by the DON, that the hospital had standing admit orders. She indicated she didn't understand how you could have standing orders for a patient's admit when you didn't know the patient or their history. S6LPN further indicated the staff had sometimes gone off of medication lists that had not been current and had initiated medications that the patient had no longer been taking. S6LPN reported the physician/LIP usually saw newly admitted patients within 24 hours of admission.

In an interview on 11/5/19 at 3:27 p.m. with S2DON, she confirmed nursing staff should have been calling the admitting physician/LIP and should have reviewed all information on the admission orders, including medication orders, with the physician. S2DON indicated it was not acceptable for the nursing staff to write orders as verbal orders without actually calling the physician/LIP to obtain the orders.

2) Failure of the RN to ensure patient vital signs were taken and recorded every 4 hours, for 24 hours, as ordered.
Review of Patient #9's medical record revealed an admission date of 10/24/19 with an admission diagnosis of Dementia with behavioral disturbances and co-morbid diagnoses including Hypertension, Cardiac Disease, and having a pacemaker.

Review of Patient #9's physician's orders revealed the following order on 10/30/19 at 10:10 a.m.: Increase Lisinopril 20 mg BID Catapres 0.1 mg po q 6 hours PRN Systolic Blood Pressure greater than 160. Recheck in 1 hour after dosage. Give another and notify provider.
Vital Signs q 4 hours x 24 hours while awake.

Review of Patient #9's entire medical record and a document titled, "Frequent Vital Signs Record" used for increased frequency of vital sign recording, revealed on 10/30/19 vital signs were only obtained on 10/30/19 at 7:29 p.m. and 11:20 p.m. and on 10/31/19 at 3:10 a.m. No further vital sign documentation was noted.

In an interview on 11/5/19 at 9:20 a.m. S2DON indicated she had reviewed Patient #9's medical record and confirmed the patient's vital signs had not been obtained and documented every 4 hours for 24 hours, as ordered.