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The condition of Patient Rights is not met based on the facility's failure to protect and promote each patient's right.

a. Based on a review of the clinical record, staff interviews and a review of the facilities policies and procedures for one of ten sampled patients (Patient #1) reviewed for an alteration in mentation, the facility failed to promote the patient's right for a safe enviornment. Refer to A 0144.

b. Based on a review of the clinical record, staff interviews and a review of the facilities policies and procedures for one of ten sampled patients (Patient #1) reviewed for an alteration in mentation, the facility failed to ensure the least
restrictive intervention was utilized to protect the patient from harm.
Refer to A 0165.

The standard of Patient Rights was not met based on the facility's failure to provide care in a safe setting.


Based on a review of the clinical record, staff interviews and a review of the facilities policies and procedures for one of ten sampled patients (Patient #1) reviewed for an alteration in mentation, the facility failed to promote the patient's right for a safe enviornment. The findings include:

Patient #1 was admitted to the facility on 12/6/12 with complaints of increased agitation, confusion, paranoia, delusional thinking and limited cognitive functioning.
Patient #1 ' s diagnoses included schizoaffective disorder, korsakoff syndrome and dementia. Patient #1 exhibited wandering behavior, disorientation, intermittent aggression, difficulty with redirection, and required assistance with eating, ambulation, and toileting.
In addition, the admission history and physical dated 12/6/12 identified in part, that Patient #1 attempted to eat his socks and required the use of posey restraints for behavioral symptoms.
Nurse ' s notes dated 12/6/12 and 1/31/13 identified Patient #1 often grabbed for objects on staff members person and attempted to place a call bell in his/her mouth multiple times and/or tried eating the callbell.
Interviews with Registered Nurse (RN)# 1, RN #2, Psychiatric Technician # 1 Psychiatric Technician # 2, and Physician # 1 conducted on 3/6/12 and 3/7/12 indicated Patient #1 had behaviors that included several attempts to place objects in his/her mouth.
Interview with Nurse Manager #1 on 3/6/13 at 11:00 AM identified Patient #1 was attended to by a " sitter " on both the day and evening shift from 12/12/12 through 2/13/13, at the time the resident was identified in an emergent situation. Additionally, Nurse Manager #1 identified that sitter observation was initiated based on nursing judgement and was used only until the resident fell asleep.
According to the facility policy for 1:1 observation, "the sitter's sole focus is to observe their assigned patient(s) behavior and safety. The sitter must not leave the patient unless another qualified employee takes over that responsibility."
Physician ' s orders dated 2/13/13 directed the use of a vest restraint on the night shift for confusion, inability to follow simple commands, agitation, attempting to climb out of bed and an inability to ambulate independently.
Nurse's notes dated 2/13/13 at approximately 11:20 PM Patient #1 was having difficulty breathing and a rapid response was initiated. Subsequent respiratory arrest ensued and prior to intubation latex gloves were found in the posterior pharynx and removed. Patient #1 was resuscitated with cardiac compressions/ventilation and was transferred to the intensive care unit.
According to the physician's discharge summary dated 2/24/13, Patient #1 was placed on comfort measures per the family's wishes and expired on 2/24/13.
Interview with psychiatric technician (PT) #1 on 3/6/13 at 1:00 PM indicated he assisted Patient #1 to bed with two other staff members on the evening of 2/13/13 at 10:20 PM and staff utilized latex gloves as a universal precaution in providing care. PT #1 identified Patient #1 was placed in a posey vest at bedtime however he/she could move his/her arms freely. Further interview with PT #1 indicated he stayed with the patient until he/she fell asleep at approximately 10:30 PM and " sitter " observation was discontinued at that time. Interview and review of the clinical record with Nurse Manager #1 on 3/7/13 at 12:30 PM identified the gloves removed from Patient #1 ' s mouth appeared to be used gloves and were wrapped one inside of another.
The facility failed to ensure the patient's environment remained free of objects, despite the known behavior of placing objects in the mouth.

The standard was not met as evidenced by the use of a device that restricted movement during the hours of sleep, when the 1:1 observation was discontinued.

Based on a review of the clinical record, staff interviews and a review of the facilities policies and procedures for one of ten sampled patients (Patient #1) reviewed for an alteration in mentation, the facility failed to ensure the least restrictive intervention was utilized to protect the patient from harm. The findings include:


Interview with Nurse Manager #1 on 3/6/13 at 11:00 AM identified Patient #1 was attended to by a " sitter " on both the day and evening shift from 12/12/12 through 2/13/13, at the time the resident was identified in an emergent situation. Additionally, Nurse Manager #1 identified that sitter observation was initiated based on nursing judgement and was used until the resident fell asleep.
According to the facility policy for 1:1 observation, "the sitter's sole focus is to observe their assigned patient(s) behavior and safety. The sitter must not leave the patient unless another qualified employee takes over that responsibility."
Physician ' s orders dated 2/13/13 directed the use of a vest restraint on the night shift for confusion, inability to follow simple commands, agitation, attempting to climb out of bed and an inability to ambulate independently.
The use of the vest restraint used at hours of sleep after the 1:1 sitter left for the evening was identified as an intervention for the patient's behavior of attempting to get out of bed, despite an unsteady gait. However, the facility failed to address Patient # 1's behavior of placing objects in his/her mouth and/or failed to identify that the use of the vest restraint would not prevent the patient from placing objects in his/her mouth and/or protect the safety of the resident when the 1:1 sitter observation was discontinued.
Interview with psychiatric technician (PT) #1 on 3/6/13 at 1:00 PM indicated he assisted Patient #1 to bed with two other staff members on the evening of 2/13/13 at 10:20 PM and staff utilized latex gloves as a universal precaution in providing care. PT #1 identified Patient #1 was placed in a posey vest at bedtime however he/she could move his/her arms freely. Further interview with PT #1 indicated he stayed with the patient until he/she fell asleep at approximately 10:30 PM and " sitter " observation was discontinued at that time.
Nurse's notes dated 2/13/13 at approximately 11:20 PM Patient #1 was having difficulty breathing and a rapid response was initiated. Subsequent respiratory arrest ensued and prior to intubation latex gloves were found in the posterior pharynx and removed. Patient #1 was resuscitated with cardiac compressions/ventilation and was transferred to the intensive care unit. Patient #1 was placed on comfort measures.
On 2/15/13 an electroencephalography revealed diffuse cerebral dysfunction, severe encephalopathy, probably of the anoxic type, with a remote chance for higher cortical function. The patient expired on 2/24/13.

The condition for Nursing Services is not met based on the nursing staffs failure to identify and/or address safety hazards in the environment for a patient with the behavior of placing objects in the mouth and/or the need for continous 1:1 observation. Refer to A0396

Based on a review of the clinical record, staff interviews and a review of the facility's policies and procedures for one of ten sampled patients (Patient #1), reviewed for an alteration in mentation, the facility failed to develop a comprehensive care plan that addressed Patient # 1's behavior of placing objects in his/her mouth.

The standard for Nursing Services was not met as evidenced by the failure to develop a comprehensive care plan that addressed Patient # 1's history of placing objects in his/her mouth and/or the need for continous 1:1 observation.

Based on a review of the clinical record, staff interviews and a review of the facility's policies and procedures for one of ten sampled patients (Patient #1), reviewed for an alteration in mentation, the facility failed to develop a comprehensive care plan that addressed Patient # 1's behavior of placing objects in his/her mouth. The findings include:


Patient #1 was admitted to the facility on 12/6/12 with complaints of increased agitation, confusion, paranoia, delusional thinking and limited cognitive functioning.
Patient #1 ' s diagnoses included schizoaffective disorder, korsakoff syndrome and dementia. Patient #1 exhibited wandering behavior, disorientation, intermittent aggression, difficulty with redirection, and required assistance with eating, ambulation, and toileting.
In addition, the admission history and physical dated 12/6/12 identified in part, that Patient #1 attempted to eat his socks and required the use of a posey restraint for behavioral symptoms.
Nurse ' s notes dated 12/6/12 and 1/31/13 identified Patient #1 often grabbed for objects on staff members person and attempted to place a call bell in his/her mouth multiple times and/or tried eating the call bell.
Interviews with Registered Nurse (RN)# 1, RN #2, Psychiatric Technician # 1 Psychiatric Technician # 2, and Physician # 1 conducted on 3/6/12 and 3/7/12 indicated Patient #1 had behaviors that included several attempts to place objects in his/her mouth.
Interview with Nurse Manager #1 on 3/6/13 at 11:00 AM identified Patient #1 was attended to by a " sitter " on both the day and evening shift from 12/12/12 through 2/13/13, at the time the resident was identified in an emergent situation. Additionally, Nurse Manager #1 identified that sitter observation was initiated based on nursing judgement and was used only until the resident fell asleep at hours of sleep.
According to the facility policy for 1:1 observation, "the sitter's sole focus is to observe their assigned patient(s) behavior and safety. The sitter must not leave the patient unless another qualified employee takes over that responsibility."
Physician ' s orders dated 2/13/13 directed the use of a vest restraint on the night shift for confusion, inability to follow simple commands, agitation, attempting to climb out of bed and an inability to ambulate independently.
The use of the vest restraint used at hours of sleep after the 1:1 sitter left for the evening was identified as an intervention for the patient's behavior of attempting to get out of bed, despite an unsteady gait. However, the facility failed to address Patient # 1's behavior of placing objects in his/her mouth and/or failed to identify that the use of the vest restraint would not prevent the patient from placing objects in his/her mouth and/or protect the safety of the resident when the 1:1 sitter observation was discontinued.
Nurse's notes dated 2/13/13 at approximately 11:20 PM Patient #1 was having difficulty breathing and a rapid response was initiated. Subsequent respiratory arrest ensued and prior to intubation latex gloves were found in the posterior pharynx and removed. Patient #1 was resuscitated with cardiac compressions/ventilation and was transferred to the intensive care unit. Patient #1 was transferred to comfort measures and expired on 2/24/13.
Interview with psychiatric technician (PT) #1 on 3/6/13 at 1:00 PM indicated he assisted Patient #1 to bed with two other staff members on the evening of 2/13/13 at 10:20 PM and staff utilized latex gloves as a universal precaution in providing care. PT #1 identified Patient #1 was placed in a posey vest at bedtime however he/she could move his/her arms freely. Further interview with PT #1 indicated he stayed with the patient until he/she fell asleep at approximately 10:30 PM and " sitter " observation was discontinued at that time.
Interview and review of the clinical record with Nurse Manager #1 on 3/7/13 at 12:30 PM identified the gloves removed from Patient #1 ' s mouth appeared to be used gloves and were wrapped one inside of another. The facility failed to ensure the patient's environment remained free of objects, despite the known behavior of placing inedible objects in the mouth.
Interview with psychiatric technician (PT) #1 on 3/6/13 at 1:00 PM indicated he assisted Patient #1 to bed with two other staff members on the evening of 2/13/13 at 10:20 PM and staff utilized latex gloves as a universal precaution in providing care. PT #1 identified Patient #1 was placed in a posey vest at bedtime however he/she could move his/her arms freely. Further interview with PT #1 indicated he stayed with the patient until he/she fell asleep at approximately 10:30 PM and " sitter " observation was discontinued at that time.

Interview and review of the clinical record with Nurse Manager #1 on 3/7/13 at 12:30 PM identified the gloves removed from Patient #1 ' s mouth appeared to be used gloves and were wrapped one inside of another.

Further interview with Nurse Manager #1 indicated although Patient #1 ' s behavior identified that he/she placed objects in his/her mouth the nursing plan of care did not address the behavior as a problem with interventions that were individualized and included close observation at all times.


The hospital policy for treatment planning defined the design of the treatment plan was to identify and incorporate patient needs into an individualized plan of care based on clinical information gathered during admission and initial assessment. The policy directed that treatment planning would specify services and interventions needed to meet the goals and objectives derived from assessing individual needs. Interventions would also respond to emergent needs such as a danger to self or others. The policy further directed the reflection of significant changes in the individual ' s needs, current condition, including regression or progress. In accordance with the facility ' s policy on developing a treatment plan, the facility failed to ensure that Patient # 1 had a plan of care that addressed the resident ' s behavior of placing inedible objects in his/her mouth.