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Based on medical record review, policy review and interview the facility failed to protect two patients from abuse (Patient #2 & #3) of 11 medical records reviewed. This had the potential to affect seven of seven active patients on the Geropsychiatric Unit.

Findings include:

The medical record review for Patient #1 revealed Patient #1 was admitted to the Geropsychiatric unit on 07/19/15 with a diagnosis of Alzheimer Dementia with Behavior Disturbance, Major Depressive Disorder and Suicidal Ideation. Patient #1 had a sitter for one-to-one observation until 07/21/15 at 2:00 PM.

The facility's Reportable Incident Notification Private Psychiatric Service Providers reports were reviewed. The reports revealed an incident occurred on 07/21/15 which stated another patient tried to choke Patient #2. The report stated zero injuries were sustained. A second report revealed an incident occurred on 07/21/15 which stated Patient #3 was hit in the face and the neck by Patient #1.

On 09/02/15 at 6:59 AM, Staff A, the nurse who was assigned to care for Patient #1 on 07/21/15, was interviewed. Staff A reported witnessing the striking of Patient #3 in the face and witnessed Patient #1 place his/her hands on the neck of Patient #2.

The facility's General Safety policy was reviewed. The policy stated its purpose was to ensure a safe environment for patients, staff and visitors.

The facility's Patient Right's policy was reviewed. The policy stated its purpose was to ensure that all rights of the patient are guaranteed. The policy stated no patient shall be deprived of any rights.

Based on staff interview, medical record review, and policy review, it was determined the facility failed to ensure registered nurses followed policy and procedure for those patients identified as being at risk for suicide. The facility failed to ensure registered nurses followed physician orders for Clinical Institute Withdrawal Assessment for Alcohol protocol. The facility failed to ensure nursing staff completed a suicide risk assessment every two hours and documented the assessment in the medical record (A395). The facility failed to ensure the nursing care plan for each patient addressed all of the identified needs and problems, and that each identified problem had a corresponding intervention(s) (A396). The systemic effect of these practices resulted in the facility's inability to ensure the safety of the Geropsychiatric unit's seven active patients. The facility had a census of 140 patients.

Based on medical record review, policy review and staff interviews, the facility failed to ensure the RN followed policy and procedure for two patients identified as being at risk for suicide. (Patients' #4 and #9). The facility failed to ensure the RN followed physician orders for CIWA protocol for one patient. (Patient #4) The facility failed to ensure nursing staff completed a suicide risk assessment every two hours and documented the assessment in the medical record for Patient #1. A total of 11 medical records were reviewed. This had the potential to affect all of the Geropsychiatric units seven active patients.

Findings include:

1) Facility policy Care of Suicidal Patient (S-21-3P1) was reviewed. Per said policy, the purpose was to "guide staff in accurately and consistently assessing the suicidal patient and in taking appropriate actions toward preventing self harm by suicidal patients."

Step A of the Procedure specified "any patient who verbalizes ideation involving thoughts of self-harm or suicide will be placed on either Suicide Levels I or II, depending upon the intensity of the suicidal thoughts and feelings."

Step B of the Procedure specified "all patients who are being treated for emotional or behavioral disorders or who have a past history of suicide attempt will be assessed by the RN upon admission to determine the level of suicide potential the patient presents using the Suicide Lethality Scale."

Step E of the Procedure specified "an RN may independently place a patient on suicide precaution if it assessed that he/she is at risk to attempt suicidal behavior. The attending physician/consulting psychiatrist must be notified immediately. The attending physician or consulting psychiatrist will either continue the precautions or discontinue based on his or her assessment."

Step F of the Procedure specified "suicide level orders for I and II are to be renewed by the attending physician or his/her designee on a daily basis and attending physicians are to document suicide assessment on each patient visit."

2) Patient #4 was admitted to the facility on 07/19/15 with primary diagnosis of alcohol withdrawal/delirium tremens. Review of the nursing admission assessment completed 07/19/15 at 6:10 PM revealed Patient #4 had a history of anxiety, depression, panic attacks and bipolar disorder."

Twenty one (21) nursing Shift Assessments were documented during the course of Patient #4's hospitalization. Shift Assessments were completed approximately every 12 hours and included a Psych Social assessment. Sixteen (16) of the 21 psycho social assessments indicated a "deviation" from a "normal" assessment and 20 of the 21 same assessments indicated Patient #4 was "depressed."

On 07/19/15 at 9:20 PM the RN documented Patient #4 was "depressed, tearful" and "patient states he is depressed." On 07/20/15 at 8:00 AM the RN documented Patient #4 was "depressed, tearful." On 07/22/15 at 8:00 AM the RN documented Patient #4 was "anxious, irritable, demanding, inappropriate, manic, restless" and at 8:30 PM the RN documented the patient was "depressed, tearful." On 07/23/15 at 7:30 AM the RN documented the patient was "anxious, depressed, tearful", and at 8:05 PM the RN documented Patient #4 was "anxious, depressed, tearful." On 07/24/15 at 8:15 AM the RN documented the patient was "depressed, tearful", and at 8:21 PM the RN again documented Patient #4 was "depressed, tearful."

There was no documented evidence of the measures taken by the RN to address Patient #4's noted depression, including communication with the physician and/or behavioral health staff.

At approximately 10:25 PM on 07/24/15 Patient #4 was found on the floor in his room by the PCA (patient care aide). Upon entering the room and assessing the situation, the RN asked Patient #4 if he was trying to end his life to which Patient#4 replied yes. Patient #4 had reportedly attempted to use the cord from the call light and the wires from his cardiac monitor to hang self.

Based on this attempted suicide, staff should have instituted Care of the Suicidal Patient policy immediately and Suicide Level II precautions. Per said precautions, the "RN documents assessments of the patient's suicidally and continuation of suicide precautions every 4 hours."

There was no documented evidence these assessments were completed. The next Shift Assessment, which was not completed until 07/25/15 at 8:10 AM (approximately 9.5 hours after the incident), failed to include an assessment of the patient's suicidally and continuation of suicide precautions.

The next Shift Assessment was completed by the RN at 8:41 PM on 07/25/15. Utilizing the SAD PERSONS scale for suicide risk assessment, the RN documented Patient #4 scored an eight (8) out of 10 and noted Level II interventions were in place.

The next Shift Assessment was approximately 11 hours later, at 7:55 AM on 07/26/15. There was no documented evidence the SAD PERSONS scale was utilized and no indication Level I or Level II interventions were in place.

Shift Assessments continued to be done approximately every 10-12 hours, instead of every four (4) hours as per the Care of Suicidal Patient policy. The next documented SAD PERSONS scale assessment was completed on 07/27/15 at 9:30 PM, approximately 48 hours after the previous one. The RN documented Patient #4 scored a 10 out of 10 and noted Level I and Level II interventions were in place.

Shift Assessments continued to be done approximately every 10-12 hours, instead of every four (4) hours as per the Care of Suicidal Patient policy, until Patient #4 was discharged on 07/29/15. There were also no other documented SAD PERSONS scale assessments following the one completed on 07/27/15.

Review of physician orders dated 07/20/15 revealed vital signs and CIWA (clinical institute withdrawal assessment) for alcohol were to be assessed by the RN every 60 minutes until Patient #4's CIWA score was less than 6.

There was no documented evidence vital signs or CIWA scores were assessed every 60 minutes following review of the CIWA flow sheets and Clinician Flow sheets. Patient #4's CIWA score did not reach a level less than 6 until 07/24/15 at 8:00 AM. Prior to that, CIWA assessments were completed approximately every two (2) to eight (8) hours.

Staff H was made aware and confirmed these findings related to Patient #4 on 09/02/15 at 11:00 AM.

3) Patient #9 was admitted to the facility on 09/01/15 with primary diagnosis of alcohol abuse/delirium tremens. Review of the nursing admission assessment completed on 09/01/15 at 6:00 AM revealed Patient #9 had a history of anxiety, depression, panic attacks and bipolar disorder. Patient #9 was asked "are you having thoughts of hurting yourself?" and replied "yes."

The RN failed to immediately address Patient #9's suicidal thoughts and implement facility policy Care of Suicidal Patient. There was no documented SAD PERSONS scale assessment or physician notification.

The next RN Shift Assessment was completed on 09/01/15 at 7:50 AM. Utilizing the SAD PERSONS scale for suicide risk assessment, the RN documented Patient #9 scored an eight (8) out of 10 and noted Level II interventions were in place.

With Level II interventions in place, the RN should have documented assessments of Patient #9's suicidally and continuation of suicide precautions every 4 hours. The next assessment was not completed until 7:30 PM, approximately 12 hours later. There was no documented SAD PERSONS scale assessment at that time and no determination of Patient #9's suicide risk.

The next Shift Assessment was completed on 09/02/15 at 8:49 AM and lacked evidence the SAD PERSONS scale assessment was completed. There was also no determination of Patient #9's suicide risk.

The next SAD PERSONS scale assessment was completed at 11:20 AM, approximately 15 hours after the previous one was completed. The RN documented Patient #9 scored a seven (7) out of 10 and noted Level II interventions were in place.

Staff I confirmed these findings related to Patient #9 on 09/02/15 at 12:45 PM during review of the electronic medical record.


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4. The medical record of Patient #1 was reviewed. The record contained a History and Physical (H&P) completed on 07/19/15. The H&P stated Patient #1 was a 69 year old patient who was brought to the Emergency Department due to Suicidal Ideation.

The H&P stated Patient #1 had severe depression in the past and responded to Electroconvulsive Therapy (ECT, a procedure in which electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental illnesses treatments). The H&P stated Patient #1 was recently diagnosed with dementia and recently was severely confused. Patient #1 will be placed on one-to-one sitter for safety and will be observed when Patient #1 is in the unit. The medical record review revealed Patient #1 had a sitter for one to one suicide precautions from 07/19/15 at 07:30 AM through 07/21/15 at 3:00 PM. The medical record review for Patient #1 revealed Suicide Risk Assessments were completed as follows:
07/19/15: 3:31 PM, 6:38 PM, 10:40 PM
07/20/15: 10:30 AM, 2:30 PM, 6:01 PM, 2:30 PM

The agency's Suicide Risk Assessment/Reassessment, Observation and Interventions policy was reviewed. The policy stated a registered nurse will reassess patients who are on suicide safety plans every two hours using the "Suicide Risk Reassessment Form".

On 09/03/15 at 12:49 PM, the findings were shared with Staff E and confirmed. Staff E reported the Suicide Risk Assessments should have been completed every four hours.

Based on medical record review and staff interview, the facility failed to ensure the nursing care plan for each patient addressed all of the identified needs and problems, and that each identified problem had a corresponding intervention(s). This affected three of 11 patients whose medical records were reviewed, Patients' #1, #4 and #9.

Findings include:

1) Patient #4 was admitted to the facility on 07/19/15 with diagnosis of alcohol withdrawal/delirium tremens. Review of the nursing care plan revealed five (5) identified problems: nutrition deficit, nausea/vomiting, gas exchange impairment, fall risk and anxiety. There were no documented interventions to address the problems.

On 07/24/15 Patient #4 reported attempting to commit suicide. This problem was not identified and added to the nursing care plan.

2) Patient #9 was admitted to the facility on 09/01/15 with diagnosis of alcohol abuse/delirium tremens. Review of the nursing admission assessment completed on 09/01/15 at 6:00 AM revealed Patient #9 had a history of anxiety, depression, panic attacks and bipolar disorder. Patient #9 was asked "are you having thoughts of hurting yourself?" and replied yes. This was not identified as a problem on Patient #9's current nursing care plan.

3) Staff G was made aware of and confirmed these findings related to Patients' #4 and #9 during review of the electronic medical record on 09/03/15 at 10:03 AM.

4. Patient #1 was admitted to the facility on 07/19/15 with a diagnosis of severe depression and suicidal ideation. The medical record review revealed Patient #1 assaulted two patients (Patient #2 and #3) on 07/21/15 at 9:30 PM. Review of the nursing care plans revealed Violence was not identified as a problem on Patient #1's nursing care plan until 08/17/15.

Based on medical record review, facility procedure review and interview, the facility failed to maintain an accurate medical record on one inpatient (Patient #1) of 11 medical records reviewed. This had the potential to affect all of the facility's 140 active patients.

Findings include:

Review of the medical record for Patient #1 revealed Patient #1 was admitted to the medical to the Geropsychiatric unit on 07/19/15 with a diagnosis of Alzheimer Dementia with Behavior Disturbance, Major Depressive Disorder and Suicidal Ideation. Review of physician orders revealed Patient #1 was ordered one to one suicide precautions on 07/19/15 which were ordered to be discontinued on 07/21/15 at 10:17 AM. The facility's Observation Flowsheets contained documentation the facility maintained one to one contact with Patient #1 during the entire day and night.

The facility's Chart Assembly/Analysis Procedure was reviewed. The procedure stated the purpose of the procedure was to ensure all medical records contain the correct patient information,

The findings were shared with Staff E on 09/03/15 at 12:49 PM and confirmed. Staff E reported the one to one observation suicide precautions had been discontinued earlier in the day and the documentation on the Observation Flowsheet was incorrect.

Based on medical record review, review of the procedures and staff interview, the facility failed to ensure physician progress notes were legible, dated and timed. This affected two of 11 patients whose medical records were reviewed, Patient #1 and #4. This had the potential to affect all of the facility's 140 active patients.

Findings include:

1) The medical record for Patient #1 was reviewed. The medical record contained handwritten progress notes from 07/20/15 at 3:40 PM, 07/21/15 at 6:00 PM and 07/21/15 at 9:40 PM. The progress notes were unable to be read in their entirety and had to be deciphered by the facility's staff.

2) Patient #4 was admitted to the facility on 07/19/15 with diagnosis of alcohol withdrawal/delirium tremens and discharged to an inpatient psychiatry facility on 07/29/15. Review of the hand written Physician Progress Notes revealed 21 times where a practitioner made a note regarding Patient #4. Of those 21entries, 16 did not reveal the time at which the note was written and 15 were illegible.

Staff B and Staff C were made aware of and confirmed these findings on 09/03/15 at 8:37 AM.

The facility's Chart Assembly/Analysis/Procedure was reviewed. The procedure stated all entries in the medical record are dated.

Based on review of the medical record and Medical Staff Bylaws, the facility failed to ensure physician orders were signed promptly and that orders for consults specified the timeframe in which to complete the consultation. This affected one of 11 patients whose medical record was reviewed, Patient #4.

Findings include:

1) Review of the History and Physical for Patient #4, dictated 07/20/15 at 8:17 PM, revealed on page three (3) of four (4) under assessment and plan the following notation: "Consult behavioral medicine." The physician failed to specify when the consult was to be completed and also failed to write an order for the consultation.

The physician then ordered a "Behavioral Health Consult" on 07/24/15 at 11:00 PM, after Patient #4 allegedly attempted to commit suicide. The physician again failed to specify when the consult was to be completed, and review of the medical record revealed the Behavioral Health assessment was not completed until 07/27/15 at 12:30 PM.

Per review of the facility's Medical Staff Bylaws, page 66 regarding Consultation, "The physician requesting the consultation shall specify in the request, the date and time of the request, as well as the time period within which the consultation must be completed."

The medical record for Patient #4 also revealed physician orders that were not signed until after the patient's discharge, on 07/29/15. On 07/19/15 at 11:12 PM the RN received an order for Phenergan 12.5 milligrams as needed for nausea. The order was not countersigned by the physician until 08/17/15, 29 days later. On 07/20/15 at 8:06 AM the RN obtained a verbal order for a "physician consult" for nausea and vomiting. The order was not countersigned by the physician until 08/17/15, 28 days later.

Staff B and Staff C were made aware of and confirmed these findings on 09/03/15 at 8:37 AM.

Based on medical record review, policy review and staff interviews, the facility failed to ensure the RN followed policy and procedure for two patients identified as being at risk for suicide. (Patients' #4 and #9). The facility failed to ensure the RN followed physician orders for CIWA protocol for one patient. (Patient #4) The facility failed to ensure nursing staff completed a suicide risk assessment every two hours and documented the assessment in the medical record for Patient #1. A total of 11 medical records were reviewed. This had the potential to affect all of the Geropsychiatric units seven active patients.

Findings include:

1) Facility policy Care of Suicidal Patient (S-21-3P1) was reviewed. Per said policy, the purpose was to "guide staff in accurately and consistently assessing the suicidal patient and in taking appropriate actions toward preventing self harm by suicidal patients."

Step A of the Procedure specified "any patient who verbalizes ideation involving thoughts of self-harm or suicide will be placed on either Suicide Levels I or II, depending upon the intensity of the suicidal thoughts and feelings."

Step B of the Procedure specified "all patients who are being treated for emotional or behavioral disorders or who have a past history of suicide attempt will be assessed by the RN upon admission to determine the level of suicide potential the patient presents using the Suicide Lethality Scale."

Step E of the Procedure specified "an RN may independently place a patient on suicide precaution if it assessed that he/she is at risk to attempt suicidal behavior. The attending physician/consulting psychiatrist must be notified immediately. The attending physician or consulting psychiatrist will either continue the precautions or discontinue based on his or her assessment."

Step F of the Procedure specified "suicide level orders for I and II are to be renewed by the attending physician or his/her designee on a daily basis and attending physicians are to document suicide assessment on each patient visit."

2) Patient #4 was admitted to the facility on 07/19/15 with primary diagnosis of alcohol withdrawal/delirium tremens. Review of the nursing admission assessment completed 07/19/15 at 6:10 PM revealed Patient #4 had a history of anxiety, depression, panic attacks and bipolar disorder."

Twenty one (21) nursing Shift Assessments were documented during the course of Patient #4's hospitalization. Shift Assessments were completed approximately every 12 hours and included a Psych Social assessment. Sixteen (16) of the 21 psycho social assessments indicated a "deviation" from a "normal" assessment and 20 of the 21 same assessments indicated Patient #4 was "depressed."

On 07/19/15 at 9:20 PM the RN documented Patient #4 was "depressed, tearful" and "patient states he is depressed." On 07/20/15 at 8:00 AM the RN documented Patient #4 was "depressed, tearful." On 07/22/15 at 8:00 AM the RN documented Patient #4 was "anxious, irritable, demanding, inappropriate, manic, restless" and at 8:30 PM the RN documented the patient was "depressed, tearful." On 07/23/15 at 7:30 AM the RN documented the patient was "anxious, depressed, tearful", and at 8:05 PM the RN documented Patient #4 was "anxious, depressed, tearful." On 07/24/15 at 8:15 AM the RN documented the patient was "depressed, tearful", and at 8:21 PM the RN again documented Patient #4 was "depressed, tearful."

There was no documented evidence of the measures taken by the RN to address Patient #4's noted depression, including communication with the physician and/or behavioral health staff.

At approximately 10:25 PM on 07/24/15 Patient #4 was found on the floor in his room by the PCA (patient care aide). Upon entering the room and assessing the situation, the RN asked Patient #4 if he was trying to end his life to which Patient#4 replied yes. Patient #4 had reportedly attempted to use the cord from the call light and the wires from his cardiac monitor to hang self.

Based on this attempted suicide, staff should have instituted Care of the Suicidal Patient policy immediately and Suicide Level II precautions. Per said precautions, the "RN documents assessments of the patient's suicidally and continuation of suicide precautions every 4 hours."

There was no documented evidence these assessments were completed. The next Shift Assessment, which was not completed until 07/25/15 at 8:10 AM (approximately 9.5 hours after the incident), failed to include an assessment of the patient's suicidally and continuation of suicide precautions.

The next Shift Assessment was completed by the RN at 8:41 PM on 07/25/15. Utilizing the SAD PERSONS scale for suicide risk assessment, the RN documented Patient #4 scored an eight (8) out of 10 and noted Level II interventions were in place.

The next Shift Assessment was approximately 11 hours later, at 7:55 AM on 07/26/15. There was no documented evidence the SAD PERSONS scale was utilized and no indication Level I or Level II interventions were in place.

Shift Assessments continued to be done approximately every 10-12 hours, instead of every four (4) hours as per the Care of Suicidal Patient policy. The next documented SAD PERSONS scale assessment was completed on 07/27/15 at 9:30 PM, approximately 48 hours after the previous one. The RN documented Patient #4 scored a 10 out of 10 and noted Level I and Level II interventions were in place.

Shift Assessments continued to be done approximately every 10-12 hours, instead of every four (4) hours as per the Care of Suicidal Patient policy, until Patient #4 was discharged on 07/29/15. There were also no other documented SAD PERSONS scale assessments following the one completed on 07/27/15.

Review of physician orders dated 07/20/15 revealed vital signs and CIWA (clinical institute withdrawal assessment) for alcohol were to be assessed by the RN every 60 minutes until Patient #4's CIWA score was less than 6.

There was no documented evidence vital signs or CIWA scores were assessed every 60 minutes following review of the CIWA flow sheets and Clinician Flow sheets. Patient #4's CIWA score did not reach a level less than 6 until 07/24/15 at 8:00 AM. Prior to that, CIWA assessments were completed approximately every two (2) to eight (8) hours.

Staff H was made aware and confirmed these findings related to Patient #4 on 09/02/15 at 11:00 AM.

3) Patient #9 was admitted to the facility on 09/01/15 with primary diagnosis of alcohol abuse/delirium tremens. Review of the nursing admission assessment completed on 09/01/15 at 6:00 AM revealed Patient #9 had a history of anxiety, depression, panic attacks and bipolar disorder. Patient #9 was asked "are you having thoughts of hurting yourself?" and replied "yes."

The RN failed to immediately address Patient #9's suicidal thoughts and implement facility policy Care of Suicidal Patient. There was no documented SAD PERSONS scale assessment or physician notification.

The next RN Shift Assessment was completed on 09/01/15 at 7:50 AM. Utilizing the SAD PERSONS scale for suicide risk assessment, the RN documented Patient #9 scored an eight (8) out of 10 and noted Level II interventions were in place.

With Level II interventions in place, the RN should have documented assessments of Patient #9's suicidally and continuation of suicide precautions every 4 hours. The next assessment was not completed until 7:30 PM, approximately 12 hours later. There was no documented SAD PERSONS scale assessment at that time and no determination of Patient #9's suicide risk.

The next Shift Assessment was completed on 09/02/15 at 8:49 AM and lacked evidence the SAD PERSONS scale assessment was completed. There was also no determination of Patient #9's suicide risk.

The next SAD PERSONS scale assessment was completed at 11:20 AM, approximately 15 hours after the previous one was completed. The RN documented Patient #9 scored a seven (7) out of 10 and noted Level II interventions were in place.

Staff I confirmed these findings related to Patient #9 on 09/02/15 at 12:45 PM during review of the electronic medical record.


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4. The medical