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Based on observation, record reviews, interviews, and review of facility policies, it was determined that the facility did not meet the Condition of Participation for Patient Rights by failing to:


1. Ensure a safe environment. (A144)

2. Promote one patient's right to refuse treatment. (A154)

3. Ensure that a Licensed Independent Practitioner's order was obtained when one patient was placed in seclusion. (A168)

4. Ensure that six of ten patients' (#1, 5, 13, 10, 11, 12) were monitored while in restraints/seclusion in accordance with hospital policy. (A175)

5. Ensure that five of ten patients' (#5, 10, 11, 12, and 13) were evaluated by the physician within one hour of the implementation of restraints/seclusion. (A178)

Based on a review of clinical records, interview and policy review, for one of ten patient's reviewed for restraints (#3), the facility failed to promote the patient's right to refuse treatment. The finding includes the following:

Patient #3 was admitted to the hospital on 5/17/14 with diagnoses that included schizoaffective disorder. The record lacked evidence the patient was conserved and/or had a Power of Attorney. Review of the treatment plan initiated on 5/28/14 identified that the patient had an alteration in thought process, chronically delusional, not a danger to self or others with interventions that included in part, approach in a calm gentle manner. A physician's order dated 5/28/14 directed the following blood work be obtained, PT/INR, ammonia and TSH. The nurse's note dated 5/28/14 at 9:45 PM and 5/29/14 at 4:05 AM described the patient as alert, oriented to person, place, time and current situation, was labile, and had no delusions and/or hallucinations. A nursing narrative on 5/29/14 at 4:05 AM indicated the patient was awake almost the entire shift and stated that he/she was not taking any medications and/or giving any blood. The note further reflected per the MD order, patient's blood was drawn against will at 6:00 AM, the patient spit in the lab technician's face then was held down and blood drawn. The record lacked evidence that alternative measures were tried prior to restraining the patient and/or that the physician deemed the patient incompetent to make informed decisions about his/her care. Interview with MD #1 on 11/6/14 at 11:00 AM stated it is within his right to order a therapeutic hold for lab drawing and is not aware of any statute that would prevent that. Review of the "Restraint" policy identified that the patient has the right to be free from restraints in any form. Although the policy addressed therapeutic hold for medication administration, it failed to address therapeutic hold for laboratory testing against will.

Based on tour and interview, the facilty failed to ensure a safe environment. The finding includes the following:

a. During tour of the Behavioral Health Unit with the Hospital Administrator on 11/5/14, a tour of the patio area, frequently utilized by staff and patients, was completed. Access to the patio was locked, which was accessed during tour, however, when return from the patio was attempted, it was identified that a key had broken off in the lock of the door with no access back into the building. There was no mechanism in place to contact staff for assistance (e.g. callbell system and/or telephone) in the outdoor patio area. During interview on 11/5/14, the Administrator stated s/he was informed that the lock had been broken for some time and that staff had wedged the outer door open when utilizing the outdoor patio to ensure access to the building.

Based on a review of clinical records, interview and policy review, for one of ten patients' reviewed for restraints (#14) the facility failed to ensure that a Licensed Independent Practitioner's order was obtained for the use of restraints. The finding includes the following:

a. Patient #14 was admitted on 4/23/14 with dementia. Review of the restraint log indicated the patient was placed in seclusion on 6/5/14. Record review and interview with the Manager of Quality Improvement identified that although the patient was placed in seclusion on 6/5/14 at 5:45 PM for approximately thirty-minutes, a physician's order for seclusion was not present in the record. Review of the policy indicated that a physician's order is required to apply and/or continue restraints.

Based on a review of clinical records and policy review, for six of ten patients' reviewed for restraints (#1, 5, 10, 11, 12, and 13) the facility failed to monitor the patient while in restraints/seclusion in accordance with hospital policy. The findings include the following:

a. Patient #1 was admitted on 9/26/14 with dementia with agitation. A physician's note dated 9/29/14 identified that the patient fell for the second time and that a seatbelt was ordered as a restraint. The clinical record failed to reflect the patient was monitored when the seatbelt was utilized.

b. Patient #5 was admitted on 9/11/14 with dementia and post-traumatic stress disorder (PTSD). Review of the clinical record indicated that the patient had been placed in seclusion on seven (7) occasions for the period of 9/12/14 through 11/1/14. The record indicated that on 9/12/14 at 2:13 AM the physician's order directed seclusion. Although the fifteen minute check flow sheet indicated the patient was in seclusion for the period of 1:30 AM through 5:00 AM, the record failed to reflect that the patient was monitored per facility policy (e.g. vital signs, fluids and toileting should be documented every two hours)

c. Patient #10 was admitted to the hospital on 2/3/14 with depression and suicidal ideation. Review of the clinical record indicated that the patient was placed in seclusion on 2/8/14 for combative and physically assaultive behavior. Review of the Seclusion Observation Form failed to reflect that the patient's vital signs were monitored every 2 hours while in seclusion as per policy.


d. Patient #11 was admitted to the hospital on 9/23/14 with Lewy body dementia with behavioral disturbance. Review of the clinical record indicated that the patient was placed in seclusion on 2/8/14 for combative and physically assaultive behavior. Review of the Seclusion Observation Form failed to reflect that the patient's vital signs were monitored every 2 hours while in seclusion as per policy.


e. Patient #12 was admitted to the hospital on 8/25/14 with depression and dementia with behavioral disturbances. Review of the clinical record indicated that the patient was placed in seclusion on 8/26/14 for combative and physically assaultive behavior. Review of the Seclusion Observation Form failed to reflect that the patient's vital signs were monitored every 2 hours while in seclusion as per policy.


f. Patient #13 had diagnoses that included dementia with depression. Review of the clinical record dated 8/13/14 identified that the patient was in seclusion from 9:35 AM until 12:15 PM. Review of the Seclusion Observation Form failed to reflect that the patient's vital signs were monitored every 2 hours while in seclusion as per policy.

Review of the restraint/seclusion observation form directed that care should be offered at least every two hours (food/fluid offered, repositioned, and elimination need), assess circulation, motion, and sensation while physically restrained every two hours and monitor vital signs every two hours while in seclusion.

Based on a review of clinical records, interview and policy review, the facility failed to ensure that 5 of 10 patients (Patients #5, 10, 11, 12, and 13) were evaluated by the LIP within one hour of the patient being placed in seclusion. The findings include the following:

a. Patient #5 was admitted on 9/11/14 with dementia and post-traumatic stress disorder (PTSD). Record review and interview with the Nurse Manager on 11/6/14 at 10:30 AM identified that the patient was placed in seclusion (restraint) on 9/12/14, 9/16/14, 9/30/14, 10/16/14 and 11/1/14, however the record failed to reflect that a note was completed by a licensed independent practitioner (LIP) within one hour of the use of restraints.

b. Patient #10 was admitted to the hospital on 2/3/14 with depression and suicidal ideation. Review of the clinical record indicated that a behavioral restraint was applied on 2/8/14 for combative and physically assaultive behavior. The type of restraint was seclusion. Review of the documentation failed to reflect that an evaluation was performed by the LIP an hour after restraint application.

c. Patient #11 was admitted to the hospital on 9/23/14 with Lewy body dementia with behavioral disturbance. Review of the clinical record indicated that a behavioral restraint was applied on 9/23/14 for combative and physically assaultive behavior. The type of restraint was seclusion. Review of the documentation failed to reflect that an evaluation was performed by the LIP within one hour of the use of restraints.

d. Patient #12 was admitted to the hospital on 8/25/14 with depression and dementia with behavioral disturbances. Review of the clinical record indicated that a behavioral restraint was applied on 8/26/14 for combative and physically assaultive behavior. The type of restraint was seclusion. Review of the documentation failed to reflect that an evaluation was performed by a LIP within one hour of the use of restraints.

e. Patient #13 was admitted on 8/11/14 with dementia. Review of the clinical record indicated that 8/11/14 the patient placed in seclusion at 10:30 PM. The clinical record failed to reflect that a 1:1 LIP evaluation had been completed.


Review of the facility policy directed that the physician perform a one (1) hour face to face evaluation of the escalating patient and provide the order for seclusion. The physician is expected to document the initial face to face evaluation with subsequent evaluations to include the patients immediate situation, reaction to the intervention, medical and behavioral condition including a complete review of systems, behavioral assessment, medications, labs and the need to continue or terminate the restraints.

Based on observation, record reviews, interviews, and review of facility policies, it was determined that the facility did not meet the Condition of Participation for Nursing Services by failing to:


1. Ensure that two patient's (#8 and #9) received the correct diet in accordance with physician orders. (A395)

2. Ensure that nine of twelve patients' reviewed for altered nutrition and weight loss (#2, 7, 5, 4, 10, 11, 12, 13, and 14) were appropriately monitored to maintain acceptable parameters of nutritional status. (A395)


3. Provide sufficient fluids and/or monitor the patient's fluid intake in accordance with the plan of care and facility policy for six of ten patient's (#2, 7, 4, 5, 11, and 13) reviewed for intake and output monitoring. (A395)


4. Ensure that the plan of care was comprehensive to address the individualized needs of the patient and/or that the plan of care was followed for five of 14 patients reviewed (Patients #2, 4, 7, 8, and 11). (A396)

1. Based on a review of clinical records, observation, interview and policy review, the facility failed to supervise dining services to ensure two patient's (#8 and #9) received the correct diet. The findings include the following:
a. Patient #8 had a diagnosis that included depression. Review of the current physician's order directed the patient receive a reduced sodium, heart healthy diet. On 11/6/14 from 11:37 AM through 12:15 PM, the patient was observed seated at the dining room table with silverware and was provided sweet and sour chicken, mashed potatoes, and a vegetable. On the table was a salt shaker that the patient utilized regularly throughout the meal. Review of the nurse aide and RN assignment sheet identified regular diet with finger foods only and no silverware. Interview with the VP of nursing on 11/6/14 at 2:00 PM indicated that Patient #8 should not have silverware during meals at any time. The facility failed to provide the necessary supervision to ensure staff provided the patient with finger foods, intervened when the patient utilized the salt shaker, and/or removed silverware as directed on the assignment sheet.
b. Patient #9 had diagnoses that included dementia with behavioral disturbance. Review of current physician's orders directed the patient receive a mechanical soft diet with honey thickened liquids. On 11/6/14 from 11:37 AM through 12:15 PM, the patient was observed seated at the dining room table and was served unthickened soup which he/she refused. Staff then placed diet cards at each patient's place setting. Review of Patient #9's diet card identified mechanical soft diet with honey thickened liquids and pureed soup. The patient was then served a chicken leg, mashed potatoes and vegetables, which he/she refused. Review of the nurse aide and RN assignment sheet indicated the patient was on regular diet and not a mechanical soft diet with honey thickened liquids per physician's orders. Interview with the Dietician on 11/6/14 at 1:30 PM stated staff should be placing the diet card at each place setting prior to food being served to ensure the patient receives the correct meal. The facility failed to ensure the patient received his/her noon meal in accordance with the physician's order.

2. Based on a review of clinical records and interview, the facility failed to identify, implement, monitor, and modify interventions, consistent with the patient's assessed needs, choices, and goals to maintain acceptable parameters of nutritional status for nine of twelve patients' reviewed for altered nutrition and weight loss (#2, 7, 5, 4, 10, 11, 12, 13, and 14). The findings include the following:
a. Patient #2 was admitted on 3/15/14 to the hospital from an acute care hospital on a Physician Emergency Certificate (PEC) order with acute confusional state, dementia and urinary tract infection (UTI). Review of the history and physical (H & P) dated 3/15/14 identified that the patient's medical history included diabetes mellitus (DM), hypertension (HTN) and hypercholesterolemia. Review of the Admission Nutritional Risk Assessment dated 3/17/14 and interview with the Registered Dietician (RD) on 11/6/14 at 1:20 PM identified that Patient #2 was 161 pounds on admission and was placed on a regular diet with a 1655.49 Kcalories need per day. Review of the care plan indicated that the patient had a potential for altered nutrition and the goal was to keep the patient at a stable weight with 75% intake or greater. Interventions included monitor oral (po) intake per policy, offer choices if less than 50% intake, provide set-up assistance as needed and assist with feeding tasks as appropriate.
Review of the Nurse Aide Documentation Tools from 3/15/14 - 4/7/14 failed to reflect the daily % intake and indicated that the patient was independent for feeding and meals were set-up. The patient weighed 133 on 4/8/14. Patient #2 had a 28 pound weight loss in 3 weeks (from 3/15/14 to 4/8/14) and had developed oral-pharyngeal candidiasis while hospitalized in the BHU. Review of the record and interview with the RD identified that the patient was not reassessed for the significant weight loss until the patient was admitted to the medical unit on 4/7/14. The RD identified that there was no order and/or request for a nutritional reassessment. The hospital did not have a policy for nutritional reassessment orders. The care plan failed to reflect altered nutrition revisions. Review of the Progress Notes dated 3/24/14 - 4/3/15 and interview with APRN #1 on 11/6/14 at 11:10 AM identified that the patient was eating and drinking fairly, adequately and/or better per staff. Although the daily Psychiatric Progress Notes identified that the nurses notes, consults, dietary, nurse aide records were reviewed, interview with APRN #1 indicated that he/she did not recall the patient's poor intake, was not notified of the poor intake and/or that the record failed to reflect % meal intake. Interview with Person #1 on 11/17/14 identified that Patient #2 was not assisted with meals and needed to be fed. Subsequently, Patient #2 had a 28 pound weight loss, was transferred to hospice care and expired in May, 2014.
b. Patient #7 was admitted on 9/24/14 with dementia with behavioral disturbances and diabetes. The patient's primary language was Spanish. The care plan dated 9/24/14 identified potential for altered nutrition secondary to inadequate/variable oral intake, and being "so loud", with a plan to possibly put the patient in a quiet room during meals to help him/her calm down. Additional interventions included in part, diet as ordered, supplement/snack routinely, provide set-up assistance with meal trays as needed and assist with feeding tasks, offer choices if takes less than 50% of meal, weigh weekly and as needed, monitor intake and diet tolerance, and weight trends.
Review of the dietician's assessment completed on 9/25/14 indicated the patient required 1383 Kcal daily, had poor food intake and was at risk for unintentional weight loss with non-specific interventions that included, diet as tolerated, fortified foods (mashed potatoes), honor preferences, assist with meals as needed, allow to eat at own pace, monthly/weekly weights, monitor oral intake, and recommend Glucerna 120 cc's twice daily.
The clinical record dated 9/29/14 indicated the patient's weight was 162.5 pounds (lbs). On 10/6/14 (one week later), the patient's weight was documented as 139 lbs., a 23.5 lb. weight loss. On 10/13/14, the patient's weight was documented as 135 lbs., a 5 pound weight loss in one week (total of 28.5 pounds over 15 days). The clinical record lacked evidence that the registered dietician was notified of the significant weight loss and/or that the patient was provided with assistance when needed, was provided with supplements/snacks per the plan of care, was offered alternative choices when less than 50% of the meal was consumed and/or that the plan was revised when the patient experienced a significant weight loss. Meal consumption documented by the CNA and acknowledged by licensed staff during the period of 9/24/14 through 10/6/14 failed to indicate the meal % was documented for 29 of 39 meals. On 11/5/14 during the period of 11:45 AM until 12:30 PM, Patient #7 was observed seated in the dining room with his/her meal placed in front of him/her. The patient had his/her eyes closed and was intermittently screaming. Staff were observed to stop and stand next to the patient, bend over and offer a bite of food, and then leave the patient's side. Staff failed to move the patient to a quiet room in accordance with the plan of care. The patient was subsequently removed from the dining area after an intake of 240 cc's of liquid only. Interview with the Occupational Therapist on 11/5/14 at 12:50 PM indicated that s/he takes Patient #7 outside at times to feed the patient since the patient has poor intake. Interview with the RD on 11/6/14 at 1:20 PM stated that all patient's are evaluated on admission and are only re-evaluated at the request of the physician and/or nurse. Interview with MD #1 on 11/6/14 at 11:00 AM identified that s/he was aware of the weight loss and knew the patient wasn't eating.

c. Patient #5 was admitted on 9/11/14 with dementia and post-traumatic stress disorder (PTSD). The care pan dated 9/11/14 identified potential for alteration in nutrition related to inadequate/variable intake with interventions in part, regular diet as ordered, monitor intake per policy, offer choices if takes less than 50% of meal, weigh weekly and as needed, notify the physician of more than a three (3) pound weight change, monitor intake and diet tolerance, and weight trends.
Review of the clinical record indicated that on 9/12/14 the patient's weight was 139 lbs. As of 11/12/14, no weekly weights had been completed.
Review of the patient's meal intake documented by the CNA and acknowledged by licensed staff during the period of 9/11/14 through 11/10/14 failed to indicate meal consumption was documented for 110 of 120 meals.

d. Patient #4 was admitted to the hospital on 9/16/14 with depression and suicidal ideation. Review of the patient's care plan included an intervention: monitor oral (po) intake per policy. Review of the patient's CNA documentation tools dated 9/16/14 through 11/2/14 failed to reflect that the patient's % intake was monitored and documented daily for each shift.

e. Patient #10 was admitted to the hospital on 2/3/14 with depression and suicidal ideation. Review of the patient's care plan included an intervention: monitor po intake per policy. Review of the patient's CNA documentation tools dated 2/3/14-2/24/14 (discharge) failed to reflect that the patient's % intake was monitored and documented daily for each shift.

f. Patient #11 was admitted to the hospital on 9/23/14 with Lewy body dementia with behavioral disturbance. Review of the patient's care plan included an intervention: monitor po intake per policy. Review of the patient's CNA documentation tools dated 9/23/14-10/3/14 (discharge) failed to reflect that the patient's % intake was monitored and documented daily for each shift.

g. Patient #12 was admitted to the hospital on 8/25/14 with depression and dementia with behavioral disturbances. Review of the patient's care plan included an intervention: monitor po intake per policy. Review of the patient's CNA documentation tools dated 8/25/14-9/5/14 (discharge) failed to reflect that the patient's % intake was monitored and documented daily for each shift.

h. Patient #13 was admitted on 8/11/14 with dementia. Review of the care plan dated 8/13/14 identified potential for altered nutrition with interventions that included regular diet, monitor food intake and offer alternatives if less than 50 % intake. Review of the patients meal intake for the period of 8/12/14 through 8/22/14 failed to reflect that the patient's % intake was consistently documented. Although licensed staff acknowledged the CNA documentation tool every shift, nursing failed to address incomplete documentation in an effort to monitor the patient's meal intake.

i. Patient #14 was admitted on 4/23/14 with dementia. Review of the care plan dated 4/23/14 identified deficiencies in "eating/nutrition", with interventions that included in part to monitor oral intake per policy, weekly weights, offer choices if patient takes less than 50%, monitor diet tolerance, and weight trends. Review of the clinical record during the period of 4/24/14 through 9/17/14 failed to reflect that the patient's % intake was consistently documented. Although licensed staff acknowledged the CNA documentation tool every shift, nursing failed to address incomplete documentation in an effort to monitor the patient's meal intake. In addition, review of the clinical record failed to reflect that the patient was weighed weekly during the period of 5/30/14 through 7/28/14 (4 weeks) in accordance with the plan of care.

3. Based on a review of clinical records, interviews, and policy, the hospital failed to provide sufficient fluids to prevent dehydration and/or monitor the patient's fluid intake in accordance with the plan of care and facility policy for six of ten patient's (#2, 7, 4, 5, 11, and 13) reviewed for intake and output monitoring. The findings include:


a. Patient #2 was admitted to the hospital on a PEC order with acute confusional state, dementia and urinary tract infection (UTI). Review of the history and physical (H & P) on admission, dated 3/15/14 identified that the patient's medical history included diabetes mellitus (DM), hypertension (HTN) and hypercholesterolemia. Review of the Admission Nutritional Risk Assessment dated 3/17/14 and interview with the Registered Dietician (RD) on 11/6/14 at 1:20 PM identified that Patient #2 was 161 pounds on admission and needed 1200 milliliters (ml) fluid requirement per day. Review of the care plan indicated that the patient had a potential for altered nutrition and the goals were to keep the patient at a stable weight with 75% intake or greater and 1200 ml/day fluid requirement. Interventions included monitor oral (po) intake per policy, monitor intake and output (I & O) and if the patient did not meet the estimated fluid requirements for 2 days, assess for dehydration and report the results to the physician. Review of the I & O records identified that Patient #2 had less than 1400 ml of oral fluids in a 3 day period (between 3/24/14 - 3/26/14) and less than 1300 ml in a 2 day period x 2 (between 3/28/14 - 3/29/14 and between 4/1/14 - 4/2/14). Review of the Progress Notes dated 3/24/14- 4/3/15 and interview with APRN #1 on 11/6/14 identified that the patient was eating and drinking fairly, adequately and/or better per staff. APRN #1 indicated that the nurses notes, consults, dietary, nurse aide records were reviewed. APRN #1 was not notified of the patient not meeting the fluid requirements. Review of the record identified that the patient received intravenous (IV) fluids at 4:14 PM on 4/3/15 and subsequently, the patient was transferred to the medical unit on 4/7/14 with severe dehydration and acute renal failure. The patient's BUN/Cr were 114/3.7 on 4/8/14. Review of the record and interview with the RD identified that there was no order and/or request for a nutritional reassessment. The hospital did not have a policy for nutritional reassessment orders. The care plan failed to reflect revisions of altered fluid intake. Documentation and interviews failed to reflect Patient #2's fluid requirements were met and/or that the patient's I & O were adequately monitored.


b. Patient #7 was admitted on 9/24/14 with dementia with behavioral disturbances and diabetes. The care plan dated 9/24/14 identified potential for altered nutrition, inadequate/variable oral intake with interventions that include in part, diet as ordered, provide set-up assistance with meal trays as needed and assist with feeding tasks, monitor intake per policy, and monitor fluids with and between meals. An intervention dated 9/25/14 identified the patient required an estimated fluid intake of 1500 cc's daily and if the patient did not meet the fluid requirement for two (2) days, to assess for dehydration and report results with intake and output (I&O) totals to the physician. Review of the dietician's assessment completed on 9/25/14 indicated the patient had poor intake, required 1500 cc's of fluid per day, and was felt to have inadequate oral intake as evidenced by reported intake of less than 50%. Review of the patient's oral intake for the period of 10/11/14 through 10/22/14 indicated that the patient did not meet the 1500 cc's minimum requirements on 13 of 14 days. The patient's intake ranged from 420 cc' s to 1460 cc's. The physician progress note dated 10/22/14 indicated the patient was noted to be unresponsive, a code was called, and the patient was subsequently sent to the ED. A nurse's note dated 10/23/14 at 6:34 AM indicated the patient returned from the ED with a diagnosis of urinary tract infection and dehydration, was bolused with one liter of fluid and a loading dose of antibiotics. The clinical record lacked evidence that nursing conducted dehydration assessments when the patient was unable to consume adequate fluids and/or that the physician was notified with the I&O totals were less than 1500 cc's as stipulated in the plan of care.


c. Patient #4 was admitted to the hospital on 9/16/14 with depression and suicidal ideation. Review of the patient's care plan identified an intervention that addressed intake and output (I & O): an estimated fluid requirement was 1100 ml/day and if the patient did not meet the estimated fluid requirement x 2 days, assess for dehydration and report results with I & O totals to MD. Review of Patient #4's I & O from 10/28/14-10/29/14; 10/31/14-11/1/14 and 11/11/14-11/12/14 identified that the estimated fluid requirement was not met. Review of the record failed to reflect that the patient was assessed for dehydration and/or that the physician was notified.


d. Patient #5 was admitted on 9/11/14 with dementia and post-traumatic stress disorder (PTSD). The care pan dated 9/11/14 identified potential for alteration in nutrition related to inadequate/variable intake with interventions in part, encourage fluids with and between meals, and monitor intake per policy. An intervention initiated 9/25/14 identified an estimated fluid requirement of 1400 cc's daily and if the patient did not meet the fluid requirement for two (2) days, to assess for dehydration and report results with intake and output (I&O) totals to the physician. Review of the patient's oral intake for the period of 10/28/14 through 11/11/14 indicated that the patient did not meet the 1400 cc's minimum requirements on 12 of 14 days. The clinical record lacked evidence that nursing conducted dehydration assessments when the patient was unable to consume adequate fluids and/or that the physician was notified with the I&O totals when consumption was less than 1400 cc's as stipulated in the plan of care.


e. Patient #11 was admitted to the hospital on 9/23/14 with Lewy body dementia with behavioral disturbance. Review of the patient's careplan identified an intervention that addressed intake and output (I & O): an estimated fluid requirement was 2268 ml/day and if the patient did not meet the estimated fluid requirement x 2 days, assess for dehydration and report results with I & O totals to MD. Review of the patient's I & O from admission to discharge (10/3/14) identified that the estimated fluid requirement was not met for 10 of 11 days. Review of the record failed to reflect that the patient was assessed for dehydration and/or that the physician was notified.



f. Patient #13 was admitted on 8/11/14 with dementia. Review of the care plan dated 8/13/14 identified potential for altered nutrition with interventions that included regular diet, and ideal fluid intake while on allopurinol was 2.5-3 liters daily. Review of the patients oral intake for the period of 8/12/14 through 8/22/14 failed to reflect that the patient met the daily fluid requirements.

Review of the Intake and Output policy identified that I&O is accurately monitored to insure adequate hydration levels and that nursing staff are responsible for recording and monitoring the I&O totals.

Based on a review of clinical records, interview and policy review, the facility failed to ensure that the plan of care was comprehensive to address the individualized needs of the patient and/or that the plan of care was followed for five of 14 patients reviewed (Patients #2, 4, 7, 8, and 11). The findings include the following:


a. Patient #2 was admitted on 3/15/14 to the hospital from an acute care hospital on a Physician Emergency Certificate (PEC) order with acute confusional state and dementia. Review of the patient's care plan indicated the patient was combative with a goal to participate in therapeutic exercises and activities. The plan failed to identify which therapeutic groups that the patient should attend to assist in achieving the stated goals.


b. Patient #4 was admitted to the hospital on 9/16/14 with depression and suicidal ideation. Review of the care plan indicated that the patient was combative with a goal to demonstrate appropriate and safe management of aggressive behaviors within group. The care plan failed to identify which therapeutic groups the patient should attend to assist in achieving the stated goals.


c. Patient #7 was admitted on 9/24/14 with dementia with behavioral disturbances and diabetes. Review of the care plan dated 9/24/14 identified problems inclusive of, potential for hypo/hyperglycemia, potential for falls, potential for alteration in skin integrity, discharge planning and alteration in nutrition. The care plan failed to address that the patient's behavioral/psychosocial issues. Additionally, the care plan failed to identify which therapeutic groups the patient should attend to assist in achieving the stated goals. On 10/23/12, the patient was sent to the emergency room and diagnosed with dehydration and urinary tract infection. Review of the care plan upon return lacked evidence that the plan was revised to address these diagnoses.


d. Patient #8 had a diagnosis that included depression. Review of the current physician's order directed the patient receive a reduced sodium, heart healthy diet. On 11/6/14 from 11:37 AM through 12:15 PM, the patient was observed seated at the dining room table with silverware and was provided sweet and sour chicken, mashed potatoes, and a vegetable. On the table was a salt shaker that the patient utilized regularly throughout the meal. Review of the nurse aide and RN assignment sheet identified regular diet with finger foods only and no silverware. Interview with the VP of nursing on 11/6/14 at 2:00 PM indicated that Patient #8 should not have silverware during meals at any time. The facility failed to provide the necessary supervision to ensure staff followed the physician's order for a reduced sodium diet (salt shaker within the patient's reach) and failed to provide finger foods that did not require the use of a utensil (mashed potato).


e. Patient #11 was admitted to the hospital on 9/23/14 with Lewy body dementia with behavioral disturbance. Review of the patient's care plan indicated the patient was combative with a goal to demonstrate appropriate and safe management of aggressive behaviors within group. The care plan failed to identify which therapeutic groups the patient should attend to assist in achieving the stated goals.

Review of the Interdisciplinary Master Treatment Plan (MTP) policy identified that the plan is current, individualized, and consistent with the psychiatric and medical regimen. Objectives and interventions are individualized and relate to the identified/presenting problems. Notations about implementation of care are documented in the patient's medical record to verify status, progress, or lack there of, in relation to each objective. All documentation is dated and signed. The MTP problem, objectives, and interventions are reviewed with the Treatment team at each weekly meeting for discussion and revision. The plan of care is reviewed, evaluated, and revised as appropriate.